“It still haunts me whether I prolonged his suffering or saved his life.”
The physician whispered those words, as if he had been carrying that sentence inside him for decades. I expected uncertainty in medicine. What I never imagined, though, was how long and how memorably physicians carried it.
Like many students, I came to medicine with the belief that progress meant getting closer to certainty. Having seen organ trafficking firsthand, I became intrigued with transplant medicine and pursued xenotransplantation research. I admired the capacity for pushing what seemed impossible through scientific innovation. It felt remarkably supernatural that a pig’s kidney could be modified to function in a human being. The closer I got to medicine, however, the more questions I found that could not be answered purely scientifically.
My curiosity slowly began to shift from exploring how medicine develops through science to exploring how physicians make decisions when science does not have all the answers. This curiosity compelled me to start talking to doctors of different specialties, not in a research setting but as mentors who were sharing what has made an impression on their practice in the form of lessons learned during times of uncertainty. Time after time, the conversation never revolved around knowing the correct answer. Instead, it was about facing the difficult challenge of making the best decision despite not knowing the answer.
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In recent months, I’ve interviewed physicians across specialties regarding pivotal moments in their careers. While some shared remarkable achievements, what impressed me most was the way each remembered uncertainty.
Their accounts varied widely. Their emotions, however, did not.
One emergency physician shared the choice she made to intubate a failing patient without sufficient information. Another transplant physician pondered the impact of an intervention that might extend life but prolong suffering. One psychiatrist mentioned discussions he would remember decades after seeing patients out of the clinic.
Each story differed. Their emotions did not.
What continues to surprise me is the absence of each experience within the curriculum I’ve come to learn. In medical school, we study physiology, pharmacology, pathology, and increasingly intricate formulas for making clinical decisions. We commit countless hours learning what is already known.
Much less consideration exists for what physicians must decide when mere knowledge falls short. It is understandable that this occurs. Medicine strives for evidence-based practice. Our patients need practitioners guided by scientific rigor. However, evidence eliminates none of the uncertainty; rather, it aids navigation.
Physicians grapple daily with imperfect data versus conflicting priorities. Statistical likelihoods conflict with human individuality; honesty collides with optimism, empathy with pragmatism, in dialogues that have no perfect answer, merely the most defensible at the time.
What surprises me is that all this experience is largely absent from medical training programs. They say ethics courses teach reflection. What they fail to teach is context.
Context makes judgment necessary. Judgment resists measurement. Judgment cannot be randomized. Judgment is too complex for guidelines. Judgment emerges through reflection, experience, humility, and sometimes even regret. The same regret that I have carefully noted from the physicians I’ve spoken to.
However, we are poor stewards of judgment and medicine. Laboratory values are documented with exacting detail. Imaging studies are reviewed and archived for posterity. Surgical procedures are described meticulously and recorded carefully. Guidelines are memorized and applied faithfully. Medical advances become part of textbooks with meticulous accuracy. These stories definitely matter. The stories do not survive our physicians’ careers, though they are the ones in which the patient they encounter forces a reconsideration of prognostication. Stories where the error teaches a physician how to balance risks differently. The case that proves guidelines are no guarantee of ethics. These narratives are passed informally between colleagues on a hospital ward. Trainees learn of them secondhand during impromptu post-rounds discussions.
And while this loss of narrative matters tremendously, it matters less because residents require additional case studies. What has emerged, perhaps paradoxically, is a system that preserves objective facts of medicine but leaves subjective wisdom out. It is easy enough to hypothesize that we might train students on overtly confident decisions while withholding from them the deliberations, conflicts, or doubts that occurred prior to those decisions. Confident answers are demanded of physicians, whose patients reasonably seek reassurance. Physicians themselves reasonably offer it. Yet our failure to address uncertainty does not make it any less relevant; if anything, our response to it requires even greater judgment than our actions.
Consider the possibility of preserving such uncertainty with the same rigor reserved for scientific inquiry. Imagine future physicians learning not only treatments for diseases but also how their predecessors navigated the gray areas that accompany them.
That dialogue has eventually led to my work on establishing the Clinical Uncertainty Registry (CUR), a project that revolves around the idea of collecting physician narratives regarding clinical uncertainty for educational purposes. Instead of prompting the physicians to share their success stories or some unique clinical cases, CUR encourages them to anonymously share their personal experience when the decision could not be made based on the evidence alone. The contributors are supposed to think about the origin of their uncertainty, what they had to balance between ethically or clinically speaking, how they managed to make sense out of the situation, and whether the experience affected their further medical practice. My vision for this project is that those narratives do not stay personal. Instead, they might constitute a living educational archive that would allow everyone from students and trainees to practitioners to understand how judgment is developed throughout a lifetime spent caring for patients.
It took medicine hundreds of years to build such incredible tools for producing evidence. It may take medicine’s next revolution to develop equivalent approaches to judgment.
Science tells us what we know. Wisdom, however, often emerges at those boundaries.
Lohithasree Bode is an undergraduate student.
