John Launer: Living with uncertainty

I was recently invited to talk to a group of GP registrars about uncertainty in medicine. I resisted making a joke about not being sure if I was the right person to do it. However, once the session started I realised that I was pitching it wrongly for doctors with their level of experience.

I’d hoped to talk about what you might call existential uncertainty: how solid medical facts so often melt into thin air, how the practice of medicine seems with experience to be like a project of trial and error. “Uncertainty,” I’ve written elsewhere, “doesn’t come occasionally, singly, or in isolated categories. It’s the ocean in which we swim for most of our working lives.”1 The young doctors present were clearly expecting something more concrete and pragmatic. This included answers to questions such as, “What do you say to a parent when you’re not sure if their child’s rash is chickenpox or scabies?”

Between us we managed to find a middle ground. I hope that I helped those doctors to feel more comfortable about sharing momentary uncertainty with patients in a transparent way. At the same time I managed to touch on some wider philosophical issues to prepare them for the inevitable experience of finding out just how much of what we believe and do turns out to be questionable in the long run.

Sooner or later, all young doctors will all make diagnoses that turn out to be plain wrong: the viral cough that was a pulmonary embolus, the cognitive decline that was due to deafness, the accidental injury that resulted from domestic abuse, or the depressed child who recovered when she moved to a school where she wasn’t bullied. Their misjudgments will come in other forms too—most especially by speaking when they should have listened or giving advice when none was wanted.

Then there are certainties we hold collectively as a profession, which we’ll dismiss as poppycock in a decade or two. Like their predecessors this generation will see some conditions, treatments, and explanations be challenged and then disappear, while others will be summoned into existence in their place. (The idea that bacteria could cause peptic ulcers, for example, was totally unimaginable when I studied medicine.) Some solid truths such as broken bones and strokes may remain, although their treatment will probably change. But the way we understand other conditions will continually evolve. This will result from scientific and technological advances such as genomics and artificial intelligence, but culture and politics will also play a part.

Should we introduce trainees and medical students to the idea of existential uncertainty earlier in their careers? Some teachers might argue that we all need to focus on knowledge first and scepticism afterwards. I’m not so sure. Perhaps it would be better to warn our learners from the beginning that many of their certainties will seem like wishful confabulations over time. It might make the overconfident ones more tentative, and the thoughtful ones might be more secure in their legitimate doubts.