One of the central themes of physicians’ professional lives this past year has been the lack of certainty when addressing COVID-19. From a public health perspective, the knowledge base over the importance of face masking has changed and evolved while the risks and benefits of various formulations of COVID vaccines have shifted. From a patient care perspective, what constitutes an effective and safe therapeutic against SARS-CoV-2 has been less a certainty and more of an evolving science. Although these gaps in knowledge are expected in medicine, they feel more significant now and are probably likely to increase. The public has confronted the widespread uncertainty as well, and has had to struggle to learn how to adapt to the evolving knowledge base. 

Uncertainty, which is the conscious awareness of not fully knowing, is central to the experience of caring for patients.1 Diagnostic, prognostic and treatment processes in patient care are all predicated on the identification and management of uncertainty that result from imperfect and sometimes limited medical information. Physical examination, testing, and radiology reduces but does not eliminate uncertainty in diagnosis. Empiric trials of medication or reducing the risk of poor outcomes through evidence-based therapy also decreases uncertainty, but regrettably, nothing can entirely eliminate uncertainty. As William Osler said, “Medicine is a science of uncertainty, and an art of probability.” 

The ‘Dunning-Kruger Effect’

While all physicians must manage uncertainty, how they do so will vary. More importantly, as the “Dunning-Kruger effect” makes clear, there are risks to not adequately identifying uncertainty. The Dunning-Kruger effect is a cognitive bias in which a failure to recognize one’s own lack of knowledge leads to an overinflated self-assessment of competency. In other words, those who lack a particular knowledge or expertise are most at risk for not recognizing they have such a deficit.2 This cognitive bias became painfully clear to me after watching a couple of YouTube videos in preparation for what was eventually my botched plumbing repair in my home. Knowing very little about plumbing made me vulnerable to not accurately appreciating how much I needed to know about plumbing to do the repair.   


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Gather Additional Information

The most common and straightforward way of managing uncertainty is simply through gathering additional information. This may occur through further diagnostic evaluation, therapeutic trials, or consulting the literature or trusted colleagues. This is both logical and reasonable, but physicians often become aware that gathering more information may not solve the problem of uncertainty. There may come a time in a diagnostic evaluation, for example, of chest pain, when concerning etiologies have been ruled out and no further testing will identify a likely diagnosis and indeed may be more likely to cause harm. There are likely to be some patients who will be unsatisfied with simply knowing that all the dangerous possibilities have been ruled out and want to know definitively what caused their chest pain symptoms. Uncertainty makes many people uncomfortable. It is not just patients who have varying tolerances for managing the sometimes adverse psychological effects of uncertainty: Physicians seek to manage these as well, often through a variety of methods.

Some physicians manage uncertainty not by trying to overcome it with more information but by identifying the cognitive state explicitly and either drawing more attention to it or disengaging from it. The former group may manage their uncertainty by devoting more cognitive resources to grappling with it, while the latter may choose to ignore the feelings associated with it so they can avoid getting stuck. These groups both accept that while uncertainty cannot be avoided, they can address and sometimes mitigate the unpleasant psychological effects.3

Finally, another method is not to focus on the uncertainty, but rather to focus on the relationships affected by it. Some physicians find consulting with other physicians incredibly helpful in palliating some of the unpleasant feelings associated with uncertainty. Other physicians share the specifics and degree of medical uncertainty directly with patients.  This sharing of uncertainty with patients is a marked change from decades ago when physicians often chose not to reveal any of the actual uncertainty in medical decision-making, presumably because such information would be too painful or difficult for patients to bear. Now, of course, disclosing uncertainty is central to the process of shared decision-making and can help point the physician to alternative solutions in line with the patient’s preferences and interests.

Even if we as health care professionals arrive at solutions differently, what does successfully managing uncertainty look like?  For many, it means reaching a point where one recognizes that complete knowledge is rarely fully known, that surety is complicated and illusory, and that knowledge is iterative and provisional rather than definitive. Albert Einstein famously said, “The more I learn, the more I realize how much I don’t know.” This mature acceptance of uncertainty does not just belong to Nobel prize-winning physicists. Arriving at such a place is likely within the reach of all health care professionals, but may be more likely by cultivating virtues such as openness, flexibility and humility that can develop with experience.4 The challenge remains in finding a reasonable balance between accepting and resisting uncertainty and when to pursue more information and knowing when not to. At least that’s my sense. I can’t be sure about it.  

David J. Alfandre MD, MSPH is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.

References

  1. Simpkin AL, Armstrong KA. Communicating uncertainty: a narrative review and framework for future research. J Gen Intern Med. 2019;34:2586-2591.
  2. Dunning D. Chapter five – The Dunning–Kruger effect: On being ignorant of one’s own ignorance. Adv Exp Soc Psychol. 2011;44: 247–296. 
  3. Han PKJ, Strout TD, Gutheil C, et al. How physicians manage medical uncertainty: A qualitative study and conceptual taxonomy. Med Decis Making. 2021;41:275-291.
  4. Fox RC. The evolution of medical uncertainty. The Milbank Mem Fund Q Health Soc. 1980;58:1-49.

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