Nothing is carved in stone

Nothing is carved in stone

  • Issue 68

Gabriel M. Gurman
Chief editor

In the era of evidence-based medicine, it would be logical to accept as an axiom the fact that most of our activity could be considered as correct, proved, and lacking question marks. But we, physicians, must be aware that in spite of the numerous indications regarding the correctness of our decisions, there is still a place for uncertainty.

This is the topic of a recently published paper (New Engl J Med 2016;375:1713) that encourages the physician to take uncertainty as a fact of life and to try to coexist with this reality, even if it creates a feeling of vulnerability and fear about the implications of facts that are not 100% certain.

The authors, Simpkin and Schwatzstein, discuss the matter and present the various facets of this aspect of our profession, emphasising the fact that the physician’s uncertainty could project ignorance to patients, with negative effects on the relationship between the sick one and his doctor.

But uncertainty accompanies our routine activity on a daily basis. We never could be sure and never could accurately predict the patient’s reaction to treatment. We could offer him/her the fittest treatment for a specific disease, but we cannot be sure how much the patient would benefit and how much his/her individuality would influence the result of the treatment.

In life, as in medicine, the predominant colour is neither white nor black, but grey. This explains the place of uncertainty in everything we do or think.

It is our obligation to understand the impact this reality could have on our own activity.

Simkin and Schwartzstein discuss in their paper the doctors’ maladaptive responses to uncertainty, which could easily lead to work-related stress. The impossibility to assure the patient about the final result of the treatment obliges the doctor to present every single possible outcome and this might influence the patient to think, for instance, on the need for a second opinion.

But uncertainty could be accompanied by the inappropriately high cost of investigations, since it sometimes requires ordering unnecessary lab tests, and also to face the risk of false positive results, with their implications of starting futile treatment.

The presence of uncertainty is felt in our specialty too. One can never be sure about the correct dose of an induction agent, and this is why titration is needed in too many cases. Too often the prolonged effect of neuromuscular blocking drugs in some patients cannot be predicted. The anatomic area covered by a ‘classical’ spinal or epidural anaesthesia can vary from one patient to another, and only the minutes after the end of the anaesthetic procedure will offer the final result. We hardly can predict the number of days a patient is supposed to spend in the intensive care unit, and the period needed for mechanical ventilation is even more difficult to establish from the very beginning.

A very interesting point discussed in the above paper refers to the so-called black-and-white multiple choice questions, which are used in almost every kind of examination. This kind of building up of a question could give the student the belief that there is always a correct answer. This false impression could strongly influence the examined person’s future activity, since it would affect the need for tolerance to uncertainty, encountered so often in our profession.

It would be worthwhile to end this short presentation by reproducing William Osler’s well-known maxim, taken from the same paper: ‘Medicine is a science of uncertainty and an art of probability’. In my opinion, there is no way to find better words to define our profession.