A Science of Uncertainty and an Art of Probability

There is a lot of talk about team based care nowadays, and I have seen some shining examples of that, most recently when a patient at my clinic had a suicide in the family.

But at the same time, there are so many decisions – judgement calls, really – that we make every single day where there isn’t anywhere near enough time to involve team members.

I talk to patients all the time who ruminate, often at night, about the choices they made every day, and replay their conversations, reasoning and actions to the point of losing sleep and experiencing distresss.

I also know of a few clinicians who do the same thing.

I think there are a few fundamental tolerances clinicians must have:

One is tolerance of uncertainty. The other is a tolerance of being where the buck stops.

“Medicine is a science of uncertainty and an art of probability” is a famous quote by my hero, Sir William Osler, the “Father of Modern Medicine” and of bedside teaching.

This is a dichotomy: On one hand, the diagnostic possibilities in most cases are nearly endless, thus uncertainty, but at the same time, the major probabilities are usually pretty clear cut.

Our mission, should we chose to accept it (Mission: Impossible – in my case, the original series; I assume that quote is still relevant) is to embrace both the uncertainty and the need not to accept indecision.

In that moment, we are often alone.

The only way to balance these seemingly opposite notions is to acknowledge that no one can know for sure but the probability is…that is, being human and being fallible, but also possessing a certain amount of knowledge based confidence.

In my Swedish training, it was considered appropriate to consider and make a clinical decision based on “the odds”. In America, that isn’t always recognized. I agree you cannot completely skip over considering the probability of the esoteric, but how much weight do you give it?. If we don’t reign in the temptation to overestimate the odds of the esoteric, our health care will bankrupt us even faster than I imagined.

The kinds of decisions we usually need to make on our own are ones we have to live with and ones we cannot let ruin our sleep or our sanity:

Antibiotics or not? Hospital admission or not? Imaging or clinical diagnosis?

You do your best. It is all you can do. Without obsessing. Osler called that Aequanimity.

1 Response to “A Science of Uncertainty and an Art of Probability”

  1. 1 thebigscaryblogger January 7, 2020 at 9:40 am

    Interesting. Your experience of medicine as a physician and my experience of it as a patient are very different.

    Just days after you wrote this post, I suffered a pulmonary embolism that gave every indication it existed, in terms of symptoms, but failed to show up on tests run at the time. Odds-based medicine (calculated by a hematologist who knows such things intimately) went on to assure me that I didn’t have a PE and my chances of ever having one were almost infinitesimal. Whatever was causing the pain and escalating symptoms over the next 7 months, multiple doctors assured me, could not be a PE. Odds-based medicine had ruled it out early-on. I mean, what were the odds that the tests might have been wrong, and the symptoms might have been right?

    So we all played the “odds-based medicine” game and shrugged our shoulders at the symptoms. No one was too concerned. Except, of course, me. Because I was living with them and they were having an increasingly negative impact on my QOL.

    Then, one day, a routine test came back out of range, a new set of imaging was ordered, and voila! It was discovered that I did indeed have a PE in the exact location in my chest where I’d been having all the pain, and I had a DVT in my calf (again).

    This is not the first time doctors have looked at me and thought “horse,” when it fact I’ve turned out to be a zebra. You know what I mean–the rule of thumb doctors are taught: “When you hear hoof beats, think horses, not zebras.”

    I finally sat down and made a list of all the times in my life when something that “never” happens in medicine–something extremely rare that you might expect in a zebra but not in a horse–in fact did happen in my case. There are a dozen examples.

    I think a clinical decision based upon “the odds,” as you put it, is inadequate. It may protect your legal hiney, but odds are it will fail some of your patients diagnostically and in treatment…sometimes with potentially life-threatening consequences.

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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