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Uncertainty is something we hide from in medicine. As doctors, we exist to make things certain for our patients. We call it a diagnosis. We hone our skills and carry a toolbox of tests to provide it. And then we prescribe drugs to treat it.
When we meet uncertainty we cannot overcome, we get ill at ease. We grapple with uncertainty like a psychic beast in our minds and often hide it from our patients and colleagues. We know our patients are often torn with uncertainty about symptoms and what to do about them, but we’re not very good at talking to them about uncertainty. Medical school teaches us to put on a confident face. It doesn’t cover how to treat the symptoms of doubt.
Emily Silverman, creator and host of the medical podcast The Nocturnists, has been thinking deeply about uncertainty. Silverman is an internal medicine doctor and an assistant professor of medicine at the University of California, San Francisco. Earlier this year, The Nocturnists launched a 13-part series, “Uncertainty in Medicine,” featuring stories from frontline doctors, medical students, patients, and a broad array of others, to bring the topic of uncertainty into the open.
As a pediatrician who’s been in practice for over 20 years, I found the series to be brave and moving. It delves into uncomfortable areas that I often think about in my own career. I was delighted to video chat recently with Silverman, who was wonderfully engaging and thoughtful, as we explored the many tensions of uncertainty that we face in our practices.
Why is it so hard for us in the medical community to face down the subject of uncertainty?
We go to medical school to get knowledge and skills, and it feels like an additive process. You expect that you’re going to grow and learn and evolve and emerge out the other end with expertise. And we don’t really think about the negative space in there, the fact that sometimes the more you learn and know, the more mysterious the world seems, the more complex the world seems. We work in a knowledge economy, where the value is what a physician brings. And to talk about that negative space, or the gaps in knowledge, just makes us uncomfortable. It’s a threat to who we are.
In your first episode about uncertainty, you mention how the character House on the TV show always manages to solve some difficult medical mystery. In medical school, we all aspire to be that accurate and sharp. But that also comes with shame; there’s a real reticence to admit you just don’t know something. I remember being on rounds as a resident, and a question gets asked, and when you don’t know the answer, you either fake it till you make it, or you become a shrinking violet and feel like you’ve failed. We’ve become our worst enemies when it comes to facing uncertainty.
Funny you mention shame. We previously did a podcast series on the emotion of shame in medicine because it’s so prevalent. There are definitely links between shame and uncertainty. Medical culture is set up in a militaristic, drill-sergeant way. There’s nothing wrong with assessing students to help them along their growth curve. But is that being done in a nurturing, constructive frame? Or is that happening inside of an abusive frame where the goal is to take pleasure in the humiliation of this person? If we’re having to battle those kinds of darker aspects of medical culture, it’s not going to help us move into constructive conversations about uncertainty.
Sometimes we respond to patients to protect our own interests and ego.
The amount of scientific progress we’ve made in medicine the past 100 years has made us a victim of our own success and created a sense of expectations for people going into medical school. But we’re talking about scientific progress, not the humanistic side of medicine. We praise the scientific half and often leave the other half behind.
Yes. We talk a lot about medicine being both a science and an art. We take scientific discoveries and apply them to something very messy like human beings and communities. We understand the biology, and the clinical research, and we’re able to take that and apply it in a skillful and flexible way to a complex, messy human being and their values, their preferences, their life story, their practical realities.
What we realized as we were putting the series together is just how many places that uncertainty pops up. Diagnostic uncertainty is the first thing that came to mind. But it’s so much more than diagnosis. It’s about prognosis. It’s about weighing risks and benefits. It’s about shared decision-making. It’s about uncertainties like, “How much does this cost and is it worth it?”
What does it look like for doctors to lean into uncertainty?
The first thing is we remove as much uncertainty as we can. We use scientific research to ascertain truth and develop new treatments and therapies. But part of being human and part of being in the universe is there’s always going to be some degree of uncertainty. There’s a lot of irreducible uncertainty in the universe. And different types of uncertainty. There’s probabilistic uncertainty, ambiguity, complexity. And who is the one facing uncertainty? Sometimes it’s the doctor, sometimes it’s the patient, and sometimes it’s both. We have to accept and tolerate and normalize the fact that uncertainty exists. Part of being competent as a clinician is knowing how to recognize, communicate about, and work with uncertainty. And the first step in tackling a problem is to talk about it and to develop language for it.
How do you define uncertainty?
I think of it as a presence more than an absence. When you don’t know something, you think of it as an absence. But I think of uncertainty as a presence of ignorance. It’s an experience where you don’t know, but you know you don’t know. That can provoke anxiety and feel uncomfortable. But it can also feel wonderful and exciting, like when you’re sitting on the edge of your seat reading a detective book. You know you don’t know, and it’s exhilarating, and that’s what keeps you turning the page. Part of the reason why people go into medicine is because there is so much frontier that hasn’t been explored yet; there’s a questing spirit. So, uncertainty is a pervasive feeling that can tilt in different emotional directions.
You acknowledge in the series that medicine is an uncertain art. I struggle with how patients will perceive that, because they come to us with uncertainty. “What’s wrong with me, doctor?” I suspect deep down they understand there’s a lot of uncertainty in what we do, and what they’re getting into. But I feel that sometimes the patients’ expectations can be a challenge. What have you learned from your series that might help you as a clinician?
I’ve thought a lot about that. Now I use the word “uncertainty” a lot more often than I used to with patients. But you’re right. There are definitely some patients who have the expectation that they’re showing up at a doctor kiosk and they’re going to press a button and get an answer. And that can be difficult to navigate. But I think most people get that medicine is complicated and the body is complicated, and there is a limit to what we can know. And sometimes things just take time. We don’t know today, but we may know in three weeks or six weeks. It may take a few years for this disease to declare itself. Part of our challenge is to trust that our patients get that.
Medical culture is set up in a militaristic, drill-sergeant way.
I think there’s a difference between clarity and certainty that we often don’t acknowledge. We can be clear with our patients even when we’re not certain. That, to me, is a really distinct difference.
I couldn’t agree more. During the COVID-19 pandemic, there were ways in which the scientific community communicated to the public that backfired. Now there’s more distrust than ever among the public of the scientific establishment. Perhaps if scientists had said things with a little more nuance, a little more humility or uncertainty: Things are evolving, this is a pandemic, we don’t know yet, this is what we think, but that could change. Maybe that approach would have preserved trust. People might trust you more if you are humble and communicate uncertainty, than if you project a false certainty.
There’s an existential quality to uncertainty. It comes from the darker side of our imaginations. I think about the parent who brings their child to me and says, “My kid is having headaches.” They’re worried about a brain tumor or something like that. Yet we know from our experiences and medical history that it’s not that 99.9 percent of the time. But they’re coming to us with a raised emotional sensitivity. And it’s often a challenge to distract them from that deep-seated uncertainty and fear.
Definitely. When you say the dark side of uncertainty in medicine, I think about health-anxiety. It can be really debilitating if people have severe health anxiety. Sometimes it’s short term, sometimes it’s long term. Sometimes people live with that for months or years and that can be really difficult.
Have you come across any good tactics to deal with that level of uncertainty?
There’s a book called Uncertainty in Medicine: A Framework for Tolerance by a palliative care physician, Paul Han. It’s not a beach read, but he deals with all sorts of responses to uncertainty that people have. He’s careful to say we should not cast positive or negative judgments on any of these, as some patient responses could be adaptive or maladaptive, depending on the scenario. Somebody might really accept uncertainty, and we might think that’s great because that makes them enlightened. But that person could then become reckless and make risky decisions and start engaging in high-risk behaviors that could put them in danger.
So, the thing to focus on is, who are we serving? Everybody has an ego, and sometimes when patients come to us and we can’t solve their problems, we respond in ways that protect our interests, our identity, and our ego. Like, if I can’t fix this person, that means X about me. So, one thing I’ve been actively trying to do in my own practice is thinking, who are my responses serving, me or the patient?
I wonder if we are passing off uncertainty among each other. You think about a complicated patient or a patient with a significant psychological overlay to their symptoms. And the story you often hear is them going all over the place, doctor to doctor, primary care to specialist, a sub-specialist, radiology, the lab, and imaging. That’s something I worry about in our healthcare system.
You’re right. One question that came up a lot in our series is what’s the difference between slowing down and luxuriating in uncertainty and being wise and waiting for something to declare itself. When does that slide into complacency and laziness and just passing the problem on to the next person? Are you generating something new or are you just facilitating an existing process that’s not helpful?
So that’s one tension. The other tension is in primary care. Fewer and fewer doctors are going into primary care. More and more doctors are going into specialization. The specialist has a list of specific diseases they take care of. And if your patient doesn’t check the boxes and have, for example, lupus or rheumatoid arthritis, then they have to rely on their primary care doctor. So, the primary care doctor has to deal with all of this uncertainty, all of these patients who have things that aren’t easily labeled.
I think one way to build uncertainty-tolerance into the system is to really beef up and celebrate and compensate our amazing primary care colleagues who do a lot of that work. We have an episode about a patient who had a diagnostic odyssey, and her primary care doctor had no idea what the heck was going on with her, but she just stuck with her, and the story has a happy ending, but some stories don’t.
You and I are both primary care doctors, and I know what you mean. But I also think about my days where I’m seeing 22 patients. I feel like I’m a batter at home plate and the curve balls are coming at me, and I just can’t keep up. Do you think there’s a link between our tolerance for uncertainty and burnout?
Yes, definitely. We have an episode on this. You have these idealistic med students. They go into residency to become primary care doctors, whether it’s internal medicine, family medicine, or pediatrics. And over the course of residency, they spend 90 percent of their time inside the hospital. They’re taking care of people in the wards. They’re taking care of people in the ICU, the sickest of the sick. In a way, there’s a lot more certainty and control inside the hospital. You can circle back to patients whenever you want. Every single medication that they take is charted and controlled by the nurses. You know everything down to their last drop of urine.
People trust you more if you are humble and communicate uncertainty
Yes, I remember. The idea was if you can handle somebody in ICU then you can handle someone coming into the office with a sore throat. No, very different experiences.
Exactly. Primary care is really hard. You have less control than you do in the hospital. There’s all sorts of psychosocial factors that you have absolutely no control over. People have multiple complex illnesses, there’s paperwork, and the increased corporatization with 15-minute visits and the McDonald’s fast-food aspect of things. There’s just so much uncertainty in primary care.
But the way we push through that, the way we tolerate that is through our longitudinal relationships with our patients. That is the one constant—a sea of uncertainty. I know this person. I know their story. I’ve been taking care of them for years. I may not have solved number 9 and 11 on their problem list, but they keep coming back. That’s where I draw my energy, and how I push through the uncertainty.
But if you take away the continuity, and you just have this scattered schedule, they don’t build up the outpatient skills, they don’t build up the uncertainty tolerance, and they don’t know their patients, which is the one thing that we know helps people kind of barrel through the uncertainty. The uncertainty of primary care for a lot of trainees just feels like too much to take on and doesn’t feel worth it. They think to themselves, “primary care is awful.” So they graduate and do their fellowship in some specialty.
We know we’re not trained well enough in medical school around this topic of uncertainty. But the other thing you’re saying is experience matters. And experience has made me more comfortable with uncertainty.
Yes, I get the sense that the more experience one has, the more wisdom one develops around uncertainty. Sometimes, though, decades of expertise can become a sort of different form of blinders. I remember a story about a world renowned doctor who missed an atypical presentation of a disease he knew intimately. In a way, that was because of his expertise, if that makes sense.
But I feel like, as you move through your medical training and see patients and get experience, you learn how to sit with it. But it can be really lonely. We have a doctor in the series who transitioned from academic medicine to private practice. In academic medicine, he had all these world experts just a phone call away, and all these residents and med students and case conferences. It was a warm bath of expertise right in his backyard. And then he ended up going into private practice, and it was one of the first times where it hit him like a ton of bricks: He was alone with uncertainty. As a physician practicing in the wild on his own, without those resources within arm’s reach, he had to figure out how to survive it.
I think the way we do that is to find ways to face uncertainty together, as a medical team, or even depolarizing the doctor-patient relationship and realizing that the doctor and patient are on the same team, facing uncertainty together.
Well, I hope so. Earlier in my career, I saw doctors thumbing their nose at the internet. I think many of us still feel cynical and defensive when our patients come to us with information from the internet. So now I think our job is to help curate that information. Say, “Where did you get that information? Share it with me so I can help you understand it.” We have to get better at that. And now AI and ChatGPT have entered the scene. Where is AI taking us when it comes to medical certainty and uncertainty?
I think AI is going to redefine this entire landscape. The medical student who has everything memorized is going to be outdated. You can outsource that to AI. The challenge, as you say, is how do you sift through the information? How do you make sense of it? How do you make meaning and patterns
I feel mostly excited about AI. I mean, we obviously want to avoid the harms of AI, whether that has to do with privacy or bias. But we would be remiss if we didn’t tap into the excitement of this new frontier and the fact that this technology is absolutely massive and incredible, and it’s going to transform every single thing about our lives.
For me, I already feel like if I don’t have ChatGPT, it’s like not having Wi-Fi. As more scientific knowledge is being generated, and more data is being generated, we’re going to need AI to make sense of it all. But I don’t think AI will ever replace a physician.
There’s a substrate to the human-to-human interaction that can’t be replaced by silicon. And it’s more than just human touch and healing. It’s about helping people navigate the data. Patients could come in and they say, “I heard about this blood test where they test for 22 different cancer markers. Should I do it?” Or people come in and say, “I got my genome sequenced and got all this data about my genetics. Here’s the report. Can you interpret this for me?” So, the more you know, the more the goalposts of uncertainty shift away and toward new things.
Right, and that’s back to talking about a change in behavior and understanding in doctors. There may be some certainty we can create with AI but, but there’s still going to be a humanistic touch that is needed.
Yes. I’m not worried. I think we’ll keep our jobs. 
Lead image: Wiwit wiji / Shutterstock
