“At once it struck me what quality went to form a man of achievement . . . when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” John Keats, December 1817
“Medicine is a science of uncertainty and an art of probability.” Dr. William Osler
“The only thing more dangerous than ignorance is arrogance.” Albert Einstein
I recently came across a 1996 article in The Lancet [a U.K. medical journal] discussing uncertainty in clinical medical practice and its implications for quality and costs of health care. I naively thought everyone knew there were uncertainties in the practice of medicine; human beings, after all, are characterized by infinite variables. But this was being presented as a somewhat novel idea that needed to be taught in medical school. Medical students and doctors in training appeared to be threatened and impaired by their uncertainties resulting from seeing patients and these psychological responses to clinical uncertainties were even affecting which specialties they were choosing for post graduate training.
I subsequently found articles in the U.S. literature, including a 2016 article in the New England Journal of Medicine (NEJM) which opined that uncertainty might be the next medical revolution. What? Uncertainty is the next medical revolution? I decided to explore this a bit further.
From the Lancet article:
The uncertainties inherent in medical practice are the direct result of biological variability and an enormous range of interchanges between a host of factors. Clinical decision making is complex, involving intuitive as well as rational thinking. Unfortunately, the ways in which clinicians respond to uncertainty and questioning of their practice may have adverse effects on complex decision-making processes, leading, for example, to unnecessary over-investigation of patients in the desire to reduce diagnostician uncertainty to a minimum. Tolerance of uncertainty is a necessary skill for effective care—and self-preservation—as a doctor. It can also enhance experiential learning. But in a world of increasing medical knowledge, capabilities, and expectations, the extent of uncertainty is rarely discussed, despite findings that one in three necropsies disagreed with the stated cause of death.
From the New England Journal of Medicine article is the following:
Our quest for certainty is central to human psychology. . . .it both guides and misguides us. In medicine today, uncertainty is generally suppressed and ignored, consciously and subconsciously. Its suppression makes intuitive sense; being uncertain instills a sense of vulnerability in us — a sense of fear about what lies ahead. It is unsettling and makes us crave black-and-white zones, to escape this gray-scale space.
Uncertainty in medicine is mostly an epistemic uncertainty which refers to when a physician (or other health care provider) has awareness of what is not known regarding the diagnosis, treatment or prognosis of a patient and must seek additional knowledge and then face the challenge of understanding the knowledge or evidence and how it may apply to a particular patient. What are the diagnostic possibilities to put into a differential diagnosis list and what tests might need to be ordered that would lead to a correct diagnosis? What would be the best initial treatment for the patient that might alleviate the symptoms or prevent progression to a more serious problem? What needs to be done to avoid a missed diagnosis or mis-diagnosis? When do treatments and procedures need to be withdrawn in someone with a terminal illness?
The last question refers to moral uncertainty and is particularly problematic for many physicians who are faced with the decision of when to withdraw life support. Moral uncertainty is complex as it incorporates other philosophical categories of uncertainty to include epistemic (Do I know enough to make this decision?), metaphysical (Am I prolonging life or merely prolonging death? - quality vs quantity of life considerations.), and communication (Do I have the ability and confidence to have an emotional conversation with the patient or family regarding life and death and when to let go?)
For an experienced physician, the majority of clinical presentations are diagnosed during the course of the history and physical exam. Many, if not most, of these patients may require lab and/or diagnostic imaging to confirm the clinical impression. For a smaller minority, diagnosis is elusive and will require specialized study with less common imaging and/or laboratory testing techniques, perhaps with referral to a specialized regional medical center.
Medicine is an uncertain science and certainty should never be assumed. Dr. Fauci’s notorious statement, “trust the science”, was scientifically inappropriate - medical science is uncertain and should be approached with skepticism and not with trust or certainty. Randomized clinical trials, “evidence based medicine”, and published medical guidelines are all designed and motivated to lessen the uncertainty of an uncertain science. Clinicians can review and be aware of the available evidence and guidelines regarding a medical condition or treatment but must then extrapolate or translate from population level estimates in the published evidence in order to make judgments for the variability within individual patients. There is uncertainty when attempting to generalize data from clinical trials to the specific patient presenting for diagnosis and treatment. The data from the research trials may not be applicable to the patient.
A well-trained, experienced, and confident physician will look at a difficult diagnostic case as a challenge rather than a source of anxiety leading to feelings of vulnerability. Why were the authors of the Lancet article concerned there should be teaching about uncertainty to medical students in 1996? Were they observing a generation of upcoming physicians who had come to expect certainty within medicine and their encounters with patients? Was there stress and burnout amongst physicians in practice who were having difficulty coping with uncertainty? Could it be this was not as much a problem with older physicians whose educational experiences were perhaps based more in intuitive and critical thinking skills and problem solving rather than algorithms and guidelines?
The NEJM article takes the concerns regarding uncertainty tolerance further into the realm of psychology. That 2016 article described the current medical students as “digital natives” that are accustomed to instant access to technology, services, and products at “the touch of a button”. They have been raised and educated with the internet, smart phones, and texting and insist on knowing “the right answer” and are frustrated when one cannot be supplied. These future doctors perceive uncertainty as a threat.
The NEJM article continues: “Great tensions are created by the conflict between the quest for certainty and the reality of uncertainty. Doctors’ maladaptive responses to uncertainty are known to contribute to work-related stress. Physicians’ difficulty in accepting uncertainty has also been associated with detrimental effects on patients, including excessive ordering of tests that carry risks of false positive results or iatrogenic injury and withholding of information from patients. In addition, 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.” Bold emphasis mine. (If you want to take a deep dive into the psychology of uncertainty, I refer you to an NIH article from 2012 dealing with medical decision making).
Ok. So here is the bottom line on all this as I see it. These “digital native”, recent and future physicians who require certainty in medicine by having instant access to black and white answers, are apparently having difficulty coping with the uncertainties in the practice of medicine. The authors of these articles recognized too many tests on patients were being ordered in the futile effort to eliminate uncertainty. That costs money and the payors don’t like increased costs. Also, increased patient risks can result from unnecessary and excessive testing perhaps followed by treatments suggested or required by guideline algorithms that may have been derived from biased or corrupted research trial evidence.
During the past 25 years or so, medical graduates have increasingly been steeped and indoctrinated in the security and certainty offered by the framework of “evidence based medicine”, published “medical guidelines”, “best practices”, and “standard of care”. As long as a physician stays between these medical “guidance” navigational beacons, uncertainty and the anxiety it provokes can be somewhat suppressed. Conformity with published “guidance” also offers perceived medical-legal sanctuary. [Note: To discuss certainty and uncertainty in the context of what has become known as evidence based medicine (EBM), is not a criticism of the value and formality of the EBM process that may be used to inform medical decision-making, but rather to encourage recognition that there is not clinical certainty provided by or guaranteed by the available evidence.]
It has been observed that when confronted with the uncertainty of the Covid 19 pandemic, and the absence of evidence and a published guideline, physicians, health care systems, and the public health bureaucracy were not so certain, confident, and secure and found themselves to be intellectually impoverished and poorly equipped to deal with what, in the end, is a respiratory infection with an overall infection mortality rate less than 1%. The void presented by the perceived lack of evidence and certainty allowed a select group of arrogant grifters and opportunists (never let a crisis go to waste) to seize control and impose a centralized, top-down strategy that offered physicians and the public a pseudo-certainty “guidance” into which they could withdraw and alleviate their uncertainty and fear.
The Covid pandemic prompted physicians and patients to look to science for certainty. Certainty that the virus would not result in death to self or to loved ones. Certainty that the hospitals would not be over-run with patients. And “science” (otherwise known as Big Pharma and the CDC) was there to capitalize (and profit) by stepping forth and promoting and advertising a certainty solution. “Safe and effective”, they said. “95% effective” is as close to certainty as one can get unless you are Joe Biden who loudly proclaimed that “if you get vaccinated, you will not get Covid”. That sounds like 100%, which is absolute certainty and has been shown to be absolute nonsense. The arrogance of their certainty was (is) breathtaking.
During the past 3 years, there have been many transgressions by the ruling elite against science, common sense, ethics, morality, and our civil rights guaranteed in the U.S. Constitution’s Bill of Rights. But professing certainty while disregarding and denying the presence of uncertainty in medical science may have been the largest transgression. There was no uncertainty expressed by Anthony Fauci and Debra Birx as they denied the value (and superiority) of natural immunity compared with “vaccine” immunity. There was no uncertainty as they stated the only way out of the pandemic was through mRNA drug injections that were “safe and effective”. There was no uncertainty when they said, without ability to cite any significant trial data, that these genetic drugs were safe and effective in pregnancy. There was no uncertainty expressed by the CDC and the FDA as the Emergency Use Authorization for the mRNA drugs was extended to children, including infants. And don’t forget, pregnant females, children, and advanced-age seniors with co-morbidities were specifically excluded in the abbreviated research trials leading to the emergency use authorization (EUA) for the mRNA drugs.
This article was initially to be about arrogance in physicians, but I quickly came to realize the larger and more important issue at this time, a time involving the fundamental transformation of our country, is a systemic arrogance within medicine. Medicine has come to be controlled by the government, the public health bureaucracy, the 3 letter agencies of CDC, FDA, NIH, and influential academic institutions. Professional societies such as the American Board of Internal Medicine, the American Board of Family Practice, and the American Board of Pediatrics have joined together to arrogantly intimidate, suppress, and persecute any physician member who may express opinion outside the government narrative regarding the Covid response and the mRNA genetic drugs.
Our health care system has been manipulated and incentivized by the government to become corporatized with the vast majority of physicians now employed or contractually submissive to large corporate entities and health care systems. Consequently, the doctor-patient relationship has been depersonalized in a system arrogance in which the patient is often not seen as a person but merely as a job to be done cost-effectively. Many caring physicians are conflicted by the competing interests of doing what is best for the patient versus the requirements of their corporate and government bosses. Add in a low uncertainty tolerance threshold and you have an explanation for the unprecedented level of job dissatisfaction and burnout amongst practicing physicians.
Think about it. When the system becomes arrogant in its certainty, authoritarianism is emboldened and becomes totalitarian and tyrannical. As a result, physicians become conscripted (and voluntary) foot soldiers in the larger arrogant system. And that systemic arrogance is not arising from uncertainty, but rather from mis-placed certainty. It must be easy to be arrogant and certain when you have liability immunity, unlimited amount of taxpayer and big Pharma cash, and the legacy media and social media are constantly singing your praises.
And how do patients fit into all of this, for that is the relevant issue, isn’t it? It has been my experience that patients understand and are instinctively aware that there are uncertainties when it comes to serious illness and the treatments that may be offered. Most do not have an expectation of certainty to be expressed by their physicians. Informed and mature optimism and hope? Yes. But projecting certainty in the presence of an uncertain disease is perceived by the public as cognitive dissonance and arrogance. Most patients understand expressions of certainty in medical treatment outcomes to be a false promise and may lead to loss of trust and confidence in their physicians. And they expect sincerity and honesty and for physicians to be independent and compassionate advocates for their patients and not compromised mouthpieces for a corrupt government and public health bureaucracy.
Amen! The arrogance of medical certainty has destroyed many careers and lives over the past 3 years and pulled back the sheep's clothing, exposing the wolf that has always been lurking and waiting for the opportunity devour our liberties. Professional credibility in medicine and science has been forever tarnished. At least now we can see the perpetrators and the system for who/what it really is and fight them in the open. Never Forget!
Thanks for another great article Dr Askins.
Good one! The lure of certainty in an uncertain world with infinite variables.