How Certain Are You?

“Medicine is a science of uncertainty and an art of probability.”  Sir William Osler

For many years, I have found myself appreciating William Osler’s quote regarding medicine as being both a “science” and an “art” and acknowledging that much of what we do is filled with uncertainty.   Indeed, I have found myself seeing that the opposite of his quote is also true – when it comes to the practice of medicine, there is “science and art” to both uncertainty and to probability.  Yet applying both the art and science of uncertainty and probability to clinical practice is not as easy as this quote appears to make it. 

For example, this week I saw a woman in her 50s previously unknown to me who had been experiencing “chest pain” intermittently over the past several days.  While she had many cardiac risk factors, she also had many other "risk factors” for GERD as well as musculoskeletal pain, and both the history and exam were consistent with a non-cardiac source.  Her EKG was not normal, but the abnormality was consistent with some changes in the past with a subsequent “cardiac work-up” that was negative.  

Feeling convinced that this her pain was non-cardiac and that empiric treatment and “tincture of reassurance” was the appropriate next steps, I discussed my findings and recommendations with her.  She listened carefully and then posed the question that tends to pierce our clinical armor and leave us reflexively shifting into defensive mode by either going on a test-ordering spree or digging in emotionally to our position (or both):  “How certain are you doctor?” she asked. 

In that nanosecond of processing, somehow my mind found an alternative, wiser path, and rather than reactively feeling the need to answer her question, I responded with a question of my own.  “What has you most concerned?” I asked, expecting her to say that if I couldn’t be completely sure then more testing was necessary.  Instead, she answered, “I had a physician previously tell me when I had similar symptoms that if we couldn’t be absolutely sure, then we needed to do more tests.  I’d prefer not to do that as it caused both great discomfort and significant expense for me.”  I smiled and felt almost as if the spirit of William Osler was standing behind me, smiling as well.  “Yes,” I replied, “I can understand how that might have happened.  Let me tell you why I don’t think that’s necessary today.”  And she left satisfied with our plan. 

We live on the edge of uncertainty and precipice of probability every day in our work.  We don’t, however, often talk about how best to navigate it and the psychological toll that it can take.  Because of that, it can weigh us down without our even being consciously aware of it.  How about you?  How do you navigate the art and science of uncertainty and probability in your clinical work?  This certainly seems like a challenge (and even burden) worth exploring and sharing with a colleague, perhaps starting with your Buddy.  Afterall, in the world of professional uncertainty that we all navigate on a daily basis, no one should care alone.