In our digital world, answers to many questions we might pose are simply a fingertip away. Technology has made it possible to go online and conduct research that can assure us that a slight rash is simply poison ivy rather than a dread disease. We like certainty and we are grateful to the physicians who provides us with a diagnosis. When we see a physician, we want answers and oftentimes medication to cure our ills. However, Dr. Arabella L. Simpkin, a pediatrician, is a leader in promoting a new discussion highlighting the need to acknowledge and embrace medical uncertainty.
Dr. Simpkin holds faculty positions at Imperial College, London, and Massachusetts General Hospital, Boston where she has a leadership role in the inaugural Center for Educational Innovation and Scholarship.
With this group she is studying “the attributes of resilience and the tolerance of uncertainty." Why does Dr Simpkin feel we need to embrace uncertainty? From her studies, she and her colleagues determined that such an attitude is key to help prevent burnout. Her goal is to design innovative approaches to teaching medicine. I spoke with her at a small gathering in the United States celebrating the book launch of a colleague of hers from Great Britain, Richard Barker, Ph.D.: Bioscience—Lost in Translation: How precision medicine closes the innovation gap. (Oxford University Press).
Despite being aware that uncertainty exists, she says, “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,” acknowledging that this quest for certainty “both guides and misguides us.”
Dr. Simpkin both teaches and researches the concept of uncertainty, and also is founder of a program and a website called “Greyscale Spaces.” She says:
“Too often, we focus on transforming a patient’s gray-scale narrative into a black-and-white diagnosis that can be neatly categorized and labeled. The unintended consequence—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, individualized patient-centered care."
Dr. Simpkin is encouraging a shift in teaching in which there is the acknowledgment and acceptance of uncertainty. She believes this is necessary not just for physicians, but for patients and the health care system. As she pointed out in her article for the New England Journal of Medicine, which she wrote with Richard M. Schwartzstein, M.D., Beth Israel Deaconess Hospital:
"Our protocols and checklists emphasize the black-and white aspects of medicine. Doctors often fear that by expressing uncertainty, they will project ignorance to patients and colleagues, so they internalize and mask it. We are still strongly influenced by a rationalist tradition that seeks to provide a world of apparent security,” adding that “by attempting to achieve a sense of certainty too soon, we risk premature closure in our decision-making process, thereby allowing our hidden assumptions and unconscious biases to have more weight than they should, with increased potential for diagnostic error.”
Drs. Simpkins and Schwartzstein even suggest changing the language in order to change perspectives. Rather than talking about “diagnoses” they suggest that if one speaks in terms of “hypotheses” this could change expectations and help in “facilitating a shift in culture.”
Dr. Schwartzstein is Director of the Center for Education at Beth Israel Deaconess. He established the Office of Education Research for the purpose of studying the effectiveness of educational interventions on learning and patient care. He is also Director of the Academy at Harvard Medical School.
In discussing the concept of embracing uncertainty, some have pointed out that in our demand for immediate answers, we stop questioning. Although it can be frustrating, sometimes it is the uncertainty and questioning that brings about a proper diagnosis and solution. During the period in which we are seeking answers, it might be more helpful to express gratitude for the process rather than anguish over time spent during the evaluation.
Copyright 2017 Rita Watson
Arabella L. Simpkin, B.M., B.Ch., M.M.Sc, and Richard M. Schwartzstein, M.D.,"Tolerating Uncertainty — The Next Medical Revolution?" N Engl J Med 2016; 375:1713-1715 / November 3, 2016DOI: 10.1056/NEJMp1606402