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Tolerating Uncertainty

Becoming a Physician

Tolerating Uncertainty — The Next Medical Revolution? Arabella L. Simpkin, B.M., B.Ch., M.M.Sc, and Richard M. Schwartzstein, M.D.

“A t once it struck me what quality went to form a Man

of Achievement . . . when a man is capable of being in uncertain- ties, mysteries, doubts, without any irritable reaching after fact and reason.”

— John Keats, December 1817 1

These words penned by John Keats, who was a physician as well as a poet, remind us of the human struggle to live in a gray- scale space where uncertainty is rife — a space that is neither black nor white. Our quest for certainty is central to human psychology, however, and it both guides and misguides us.

Although physicians are ratio- nally aware when uncertainty exists, the culture of medicine evinces a deep-rooted unwilling- ness to acknowledge and embrace it. Embodied in our teaching, our case-based learning curricula, and our research is the notion that we must unify a constellation of signs, symptoms, and test results into a solution. We demand a differential diagnosis after being presented with few facts and ex- hort our trainees to “put your money down” on a solution to the problem at hand despite the powerful effect of cognitive biases under these conditions. Too often, we focus on transforming a pa- tient’s gray-scale narrative into a black-and-white diagnosis that can be neatly categorized and labeled. The unintended conse- quence — an obsession with finding the right answer, at the risk of oversimplifying the richly

iterative and evolutionary nature of clinical reasoning — is the very antithesis of humanistic, in- dividualized patient-centered care.

We believe that a shift toward the acknowledgment and accep- tance of uncertainty is essential — for us as physicians, for our patients, and for our health care system as a whole. Only if such a revolution occurs will we thrive in the coming medical era.

In medicine today, uncertainty is generally suppressed and ig- nored, consciously and subcon- sciously. Its suppression makes intuitive sense: being uncertain instills a sense of vulnerability in us — a sense of fear about what lies ahead. It is unsettling and makes us crave black-and-white zones, to escape this gray-scale space. Our protocols and check- lists emphasize the black-and- white aspects of medicine. Doc- tors often fear that by expressing uncertainty, they will project ignorance to patients and col- leagues, so they internalize and mask it. We are still strongly in- fluenced by a rationalist tradition that seeks to provide a world of apparent security.

Yet the reality is that doctors continually have to make deci- sions on the basis of imperfect data and limited knowledge, which leads to diagnostic uncer- tainty, coupled with the uncer- tainty that arises from unpre- dictable patient responses to treatment and from health care outcomes that are far from bi- nary. Key elements for survival in the medical profession would

seem, intuitively, to be a toler- ance for uncertainty and a curi- osity about the unknown. Have we created a culture that ignores and denies that requirement? Could our intolerance of uncer- tainty, in turn, be contributing to the accelerating rates of burnout and the rising cost of health care? For there is no doubt that absolute truth and certainty are hard to come by in clinical med- icine.

Great tensions are created by the conflict between the quest for

certainty and the reality of un- certainty. Doctors’ maladaptive re- sponses to uncertainty are known to contribute to work-related stress.2 Physicians’ difficulty in accepting uncertainty has also been associated with detrimental effects on patients, including ex- cessive ordering of tests that carry risks of false positive results or

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iatrogenic injury and withhold- ing of information from patients.3 In addition, by attempting to achieve a sense of certainty too soon, we risk premature closure in our decision-making process, thereby allowing our hidden as- sumptions and unconscious biases to have more weight than they should, with increased potential for diagnostic error.

Our need to tolerate uncertain- ty has never been more urgent. Technology is advancing at light- ning speed, and we are now able,

at the touch of a button, to get instant access to a plethora of services and products. In our ex- perience, many current medical students, the digital natives, seek structure, efficiency, and predict- ability; they insist on knowing “the right answer” and are frus- trated when one cannot be sup- plied. This attitude no doubt in- creases the likelihood that they will perceive uncertainty as a threat. Given the growth of ac- cess to information online and electronically, students can spend less time at the bedside in the gray-scale world of medicine and more time in front of a screen absorbing processed and general information rather than immedi- ate and idiosyncratic realities. Their online experience may re- inforce their sense of a black- and-white world where certainty is readily achievable — the antith- esis of the perspective they will

need to thrive in 21st-century medicine.

We believe that cultivating a tolerance of uncertainty, and ad- dressing the barriers to this goal for physicians, patients, and the health care system, will require a revolutionary change in medicine’s cultural attitude and approach to uncertainty. Our curricula (for- mal, informal, and hidden), as- sessments, and evaluations will need to be modified to empha- size reasoning, the possibility of more than one right answer, and

consideration of our patients’ values. Educators can start by asking questions that focus on “how” and “why,” not “what” — stimulating discussion that em- braces the gray-scale aspects of human health and illness, aspects that cannot be neatly catego- rized, and encouraging students’ curiosity to explore and capacity to sit comfortably with uncer- tainty, acknowledging that cer- tainty is not always the end goal.

Our curricula should recog- nize diagnosis as dynamic and evolving — an iterative process that accounts for multiple, chang- ing perspectives. We can speak about “hypotheses” rather than “diagnoses,” thereby changing the expectations of both patients and physicians and facilitating a shift in culture. This shift may entail discussing uncertainty directly with patients, intentionally re- f lecting on its origins — subjec-

tivity in the illness narrative, diag- nostic sensitivity and specificity, unpredictability of treatment out- comes, and our own hidden as- sumptions and unconscious bias- es, to name a few. We can then teach physicians specifically how to communicate scientific uncer- tainty, which is essential if pa- tients are to truly share in deci- sion making, and we can reduce everyone’s discomfort by refram- ing uncertainty as a surmount- able challenge rather than as a threat.

In keeping with these curricu- lar goals, our assessments of stu- dents can reflect the gray-scale environment, shifting away from the black-and-white multiple- choice questions that are all too common in our exams and that inculcate in students the belief that there is always a right an- swer. We need to focus on evalu- ating clinical reasoning and the demonstration of tolerance for uncertainty.

As we move further into the 21st century, it seems clear that technology will perform the rou- tine tasks of medicine for which algorithms can be developed. Our value as physicians will lie in the gray-scale space, where we will have to support patients who are living with uncertainty — work that is essential to strong and meaningful doctor–patient rela- tionships. It is therefore critical that we focus on thriving in this space and changing our profes- sional culture to allow for uncer- tainty. As faculty, we will have to model for our students the prac- tice of medicine in which it is all right to be uncertain — perhaps reminding ourselves of Osler’s maxim that “medicine is a sci- ence of uncertainty and an art of probability.”4 Ironically, only un-

We can speak about “hypotheses” rather than “diagnoses,” thereby changing

the expectations of both patients and physicians and facilitating a shift in culture.

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certainty is a sure thing. Certain- ty is an illusion.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From the Division of General Internal Med­ icine, Massachusetts General Hospital (A.L.S.), Harvard Medical School (A.L.S.,

R.M.S.), and the Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Is­ rael Deaconess Medical Center (R.M.S.) — all in Boston.

1. Forman MB. The letters of John Keats. Oxford, United Kingdom: Oxford University Press, 1931. 2. Logan RL, Scott PJ. Uncertainty in clin- ical practice: implications for quality and

costs of health care. Lancet 1996; 347: 595- 8. 3. Kassirer JP. Our stubborn quest for diag- nostic certainty: a cause of excessive testing. N Engl J Med 1989; 320: 1489-91. 4. Bean RB, Bean WB. Sir William Osler: aphorisms from his bedside teachings and writings. New York: Henry Schuman, 1950. DOI: 10.1056/NEJMp1606402 Copyright © 2016 Massachusetts Medical Society.Tolerating Uncertainty

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Copyright © 2016 Massachusetts Medical Society. All rights reserved.