“I don’t know” may be one of the most difficult phrases to both hear and admit. As a patient, fewer words can make you more anxious, and as a health care provider, fewer words can make you feel more powerless. As a whole, the medical community has fostered and embraced a culture of certainty, discouraging the phrase “I don’t know” because of the helplessness it can instill in patients and physicians alike.
Health care and its providers tend to be reluctant to confront the extent of uncertainty in medicine, which manifests as complex clinical information, unpredictable patient outcomes, and a physician’s tolerance for ambiguity, among other factors. However, treating uncertainty as nonexistent does more harm than good, leading to overtreatment, distrust within the patient-provider relationship, and physician burnout. When physicians acknowledge uncertainty openly, they strengthen the patient-provider relationship, encourage trust-based care, support shared decision-making, and help limit overconfidence. By embracing uncertainty through reframing medical education and culture, health care providers can deliver higher-quality patient care.
The harms of diagnostic certainty
Although certainty is valuable in medicine for providing patients with accurate and timely care, an overemphasis on diagnostic clarity can lead to overtesting and overtreatment, harming patients and physicians alike. The detrimental effects of searching for certainty on patients are evident when studying PSA screenings, a screening test for prostate cancer introduced in the 1980s. As the test became more widely adopted in clinical practice, the incidence of prostate cancer increased accordingly.
The uncertainty of distinguishing whether a patient’s prostate cancer is indolent or aggressive prompts overtreatment, although recent improvements in biopsy techniques and biochemical markers have reduced this ambiguity. The overdiagnosis and overtreatment of prostate cancer have been linked to a rise in cardiovascular events, anxiety, depression, and even suicide in these patients. Thus, seeking greater certainty in medicine can, at times, harm a patient’s mental and physical well-being.
Physician burnout and patient trust
Additionally, medicine’s need for certainty can negatively affect physicians. Studies highlight that health care providers with a lower tolerance for uncertainty have higher rates of burnout and anxiety, primarily when outcomes differ from what is expected or when uncertainty is stigmatized.
Surveys also found that physicians with a lower tolerance for uncertainty had lower patient experience scores, as their reluctance to share uncertainties hindered communication and trust within the patient-physician relationship. Patients preferred for their physicians to acknowledge and communicate their diagnostic uncertainty, as such honesty strengthened patients’ trust in their providers and their view of their physicians’ competency. Overall, the higher a clinician’s tolerance of uncertainty, the greater satisfaction their patients have during interactions, suggesting that patient satisfaction improves with the transparency and humility that physicians demonstrate as they embrace uncertainty.
Reframing medical education
Admittedly, an emphasis on certainty benefits medicine in some instances, such as in examinations required for licensing. However, given that an overemphasis on certainty harms patients and physicians alike, medicine must make an effort to accept and manage uncertainty in clinical settings. This movement should begin in medical schools by better training students to handle ambiguous clinical decision-making and uncertainty, which may occur through observing clinicians, speaking with patients about their experiences, role modeling, and integrating communication about and tolerance for ambiguity into the core curriculum.
Schools should reframe uncertainty as an opportunity to build ethical honesty, trust, stress-management skills, and professionalism rather than as a sign of a physician’s incompetence. Moreover, schools could strengthen students’ tolerance for uncertainty by incorporating more humanities into health care training and encouraging creative thinking, as these changes will foster students’ growth as holistic thinkers and leaders, thinking beyond the lens of medicine having definite answers.
Accrediting bodies like the LCME should also promote these core curriculum changes and standardize their implementation across institutions nationwide. Although accrediting bodies tend to focus on competency, competency and uncertainty need not be mutually exclusive. Learning to identify and embrace uncertainty can be a discernible skill reflective of competent physicians. Overall, if individual schools and accrediting bodies were to promote such training, medical students would better develop a tolerance for uncertainty in the clinical setting, preventing physician burnout and improving patient satisfaction and care.
All in all, uncertainty within medicine is unavoidable, and recognizing the connection between patient satisfaction and a physician’s tolerance for uncertainty is valuable. To develop clinicians who can best collaborate with and care for patients, medical schools must identify and address the need for students to strengthen their tolerance for ambiguity, preventing subsequent burnout, patient dissatisfaction, and distrust. It is essential to realize that one’s tolerance for uncertainty is not an innate trait but a learned skill. Thus, only with improved training at the level of medical schools will new generations of physicians be best equipped to empathetically engage with patients, prevent overdiagnosis and overtreatment, and manage provider stress.
Priya Dudhat is a medical student.
