“Caring for the dying is often very demanding. It requires not just clinical competence and the ability to communicate with honesty and compassion. It also demands that we are able to live with uncertainty and the awareness that death comes to us all.”
So wrote Rosalie Shaw in the introduction to her book Soft Sift in an hourglass – stories of hope and resilience at the end of life –
When sociologists write about medical socialisation, they refer to the learning of attitudes, norms, self-images, values, beliefs and behaviour patterns that are associated with becoming a doctor.
Shifts in interpersonal values begin before the first day of medical school – socialisation begins prior to the start of formal training. Students encounter a vast field of knowledge and soon discover that they cannot master it all. They are socialised into uncertainty.
“Uncertainty and death [are] the only certainties”.
These uncertainties can be divided into three broad areas:
Firstly, an uncertainty that accompanies their incomplete knowledge and the ever-increasing burden of information that modern medicine accumulates.
Secondly, they realise the uncertainty that flows from the gaps, deficiencies and ambiguities that accompany that information.
The third uncertainty relates to coming to terms with the dilemma of whether these gaps are there because of their own personal ignorance or rather the imperfect or deficient aspects of ‘scientific’ knowledge that medicine espouses.
As learners they often don’t know what they don’t know but they also don’t know what medicine doesn’t know. So often they see their teachers and role models behave in a way that suggests to them that those people do know, and this compounds their uncertainty.
What we in palliative care can do therefore is to celebrate the uncertainty that we face in medicine.
Our first task is to normalize the uncertainty of prognosis. Our second task is to address patients’ and surrogates’ emotions about uncertainty, acknowledging how difficult it may be for them not to know. Our third task is to help patients and families manage the effect of uncertainty on their ability to live in the here and now.
The search for certainty may impede the ability of patients and family caregivers to live in the present. They may believe that if they only knew what the future would bring, their decision making would be easier — they wouldn’t make mistakes or have to worry about regret.
Arabella Simpkin, and Richard Schwartzstein in their article “Tolerating Uncertainty — The Next Medical Revolution?” write:
“Our quest for certainty is central to human psychology … and it both guides and misguides us. Although physicians are rationally aware when uncertainty exists, the culture of medicine reveals a deep-rooted unwillingness to acknowledge and embrace it. Embodied 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.”[1]
We demand a differential diagnosis after being presented with few facts and exhort our trainees to identify a solution to the problem at hand despite the powerful effect of cognitive biases under these conditions.
Too often, we focus on transforming a patient’s sometimes murky narrative into a black-and-white diagnosis that can be neatly categorized and labelled.
What we know now is that as we move further into the 21st century, technology will perform many of the routine tasks of medicine for which algorithms can be developed. Our value as physicians will remain in that murky space that we, in palliative care, are perhaps more used to occupying.
All the people we care for are living with uncertainty, we should never forget that. We have to acknowledge to ourselves and to those who we teach that we are comfortable, indeed that we thrive, in these areas of uncertainty. We must model, for our students, that it is OK to be uncertain.
Donald Schön, in Educating the Reflective Practitioner, describes professional practice as “high, hard ground overlooking a swamp.”[2]
For palliative medicine, the high, hard ground is the scientific zone, which is fact based, predictable, and consists of solvable problems, whereas the artistic or indeterminate (murky) zone is characterized by uniqueness, conflict, and ambiguity. In palliative medicine we often practice in the artistic zone, and medical education curricula should acknowledge that some degree of anxiety is natural and predictable when operating in the artistic zone. We should strive to equip students with knowledge on how to act wisely in states of ambiguity and uncertainty.
Working in palliative care, we must teach our students that living with uncertainty is part of the job. After all, as Sir William Osler wrote “medicine is a science of uncertainty and an art of probability”. Ironically, only uncertainty is a sure thing. Certainty is an illusion.
Rod MacLeod MNZM, PhD, FAChPM
Auckland, February, 2022
Taken from the Rosalie Shaw Oration. “Certainty is an illusion” given at the ANZSPM virtual conference September, 2020
[1] Simpkin, A, Schwartzstein, R 2016 Tolerating Uncertainty — The Next Medical Revolution? N Eng J Med 375;18
[2] Schön, DA. 1987 Educating the Reflective Practitioner. San Francisco Jossey Bass
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