Medical school cannot prepare us for all the possible scenarios we are going to encounter in our medical career. In fact, I would argue that not only is this impossible, but unnecessary. We do hope that during medical school and even more so in residency future physicians will be exposed to enough clinical scenarios so that they can arrive at the right medical decision. I came across an older article by Dr. Hall that explores the physician and medical student’s reaction to uncertainty. It turns out that physicians are uncomfortable with uncertainty and their reaction to uncertainty is particularly interesting. It seems that most physicians consciously or unconsciously believe that uncertainty in treatment/diagnosis/patient wishes will lead to unease on the side of the patient and the physician will in some way lose power and dominance. Some believe that this loss of trust on the patient’s side toward the physician will lead to the patient to perhaps seek out “quacks”. To avoid this outcome physicians, continue to uphold medical orthodoxy. Physicians find some comfort that other before them have done the same in similar situations. I have always been unsatisfied with the common answer in medicine “because that is how it is done.”
Even more interesting is the observation that this fear of uncertainty “propels activity”. In otherwise uncertainty often drives unnecessary admissions, more testing, longer ICU stays, reluctance in withdrawing futile care and unnecessary surgical interventions. This is unfortunate since such activity can lead to complications and unwarranted worry of the patient. This fear of uncertainty has also led physicians to seek out specializations, particularly those with interventions and avoid patients that have chronic pain, are geriatric or have psychiatric complaints.
Physicians and medical students employ heuristics when they do face uncertainty. There is nothing wrong with using a heuristic when faced with a new situation. In fact, that is one of the traits that was thought to be uniquely human (later observed in some other higher order mammals). However, heuristic users must be aware that these shortcuts are subject to many biases including, representative bias, availability bias and regret bias, which again can lead to errors in judgment.
So how does knowing this impact medical education?
I think in several ways. 1. Students need to be taught how to be more comfortable with uncertainty. They need to be more comfortable expressing uncertainty to patients because that is both the ethical thing to do and because that is an opportunity to build a stronger patient/doctor relationship. 2. Students must be introduced to the types of biases that humans employs so they can try to avoid them when they will most certainly be faced with the inevitable uncertainty of medicine.
- Hall, Katherine H. “Reviewing intuitive decision-making and uncertainty: the implications for medical education.” Medical Education3 (2002): 216-24. Web.