Uncertainty is a hot topic lately.
That's good! Uncertainty is everywhere and we can’t deny it. Take cauda equina syndrome for example. We have to take an uncertain subjective history, consider an uncertain evidence base and make an uncertain decision. What happens to our patient after our decision is also… uncertain. So it’s great to talk openly about all that.
But I can't get past the feeling that the way we're talking about uncertainty is a bit... uninspiring?
Because everything I read about uncertainty makes it sound miserable! One paper tells me that uncertainty is something to ‘deal with’. Another tells me I need to ‘learn to tolerate' it. And another tells me I need to ‘manage it’. But I don’t want to ‘deal with’, ‘tolerate’ or ‘manage’ anything!
On top of that, we keep hearing that ‘uncertainty is inevitable’. That’s true, but when you put it like that it makes uncertainty sound like paying taxes or rainy days in England. Just another one of life's dreary misfortunes…
But what if uncertainty is actually pretty great?
In this post, I'm going to try to give uncertainty a rebrand. So here are five reasons why MSK clinicians should not merely ‘tolerate’ or ‘manage’ uncertainty in their practice, but seek it out, appreciate it, and maybe even love it!
1. Uncertainty sparks the desire to learn
Uncertainty usually feels unpleasant.
But this doesn’t mean uncertainty is bad. Because the unpleasantness of uncertainty is only one half of the equation. The other half is that we want to get rid of the unpleasantness, and we do that by learning.
Uncertainty is just one step from curiosity.
So, although uncertainty might not feel nice at first, overcoming uncertainty through learning does feel good. We should be grateful for the itch of uncertainty because we get the satisfaction of scratching it!
2. Uncertainty is the most fertile soil for personal growth
This is related to the previous point but it's deeper. It’s not just about learning information. Uncertainty also compels us to grow more as people.
Imagine if there were no mysteries in our work, no impossible decisions, no moral dilemmas, no unanswered questions… It would be stultifying. We'd stagnate. Because we need uncertain situations. Once navigated, they help us to grow as people.
Maybe this is why so many spiritual leaders explicitly encourage us to stick with uncertainty. For example, here's the Buddhist nun Pema Chödrön:
“Sticking with uncertainty is how we learn to relax in the midst of chaos, how we learn to be cool when the ground beneath us suddenly disappears. We can bring ourselves back to the spiritual path countless times every day simply by exercising our willingness to rest in the uncertainty of the present moment—over and over again”.
3. Uncertainty is the cornerstone of rationality
The naive view of rationality is that it's a process of honing in on certainty. ‘I take these pieces of information and put them in order to deduce the correct answer: This patient has knee OA’.
The sophisticated view of rationality is that it's a game of uncertainty. ‘I take these pieces of information, take stock of what information might be missing, and make a best guess at what could be the best answer. I think it's more likely than not that this patient has knee OA.’
To put it another way, uncertainty isn't where rationality ends, it's where rationality begins. Truly smart people don't think in terms of ‘correct’ or ‘incorrect’, they think in terms of likelihoods.
Or, as Mr. Rationality himself Daniel Kahnemann says, ‘an unbiased appreciation of uncertainty is the cornerstone of rationality’.
4. Uncertainty is expertise
The layperson thinks things are simple. They think A —> B —> C.
But the expert knows that, well, ‘things are a bit more complicated than that...’ They know that there are many ways of looking at their subject and many unknowns.
This is why it’s the most experienced and advanced practitioners from all walks of life who talk about uncertainty the most. One study found that even expert bridge players saw far more uncertainty in the game than their novice counterparts.
Looked at this way, uncertainty isn’t a speedbump on the way to expertise, it’s one of the core features of expertise itself. Experts don’t ‘tolerate’ or ‘manage’ uncertainty, they embrace it and study it. Their superior knowledge of the uncertainties of their field is what makes them experts, and makes them able to act more skillfully in their domain.
(This is a good time to point out that uncertainty does not necessarily entail a lack of confidence. You can be epistemologically uncertain but still personally and professionally confident.)
‘To be prepared against surprise is to be trained. To be prepared for surprise is to be educated.’ — James Carse.
5. Uncertainty allows you to have meaningful relationships with your patients
Even if, like me, you're not a very sentimental person, you'd probably agree that the interactions you have with your patients are more meaningful than, for example, the interactions you have with the plumber who comes to fix your sink. Why is that?
It’s partly because you and your patient are navigating uncertainty together.
The plumber knows the problem with your sink and he knows how to fix it, so your relationship is mostly transactional. You don't have to connect in any substantial way.
On the other hand, you aren’t wholly certain of your patient’s problem and you aren’t wholly certain of how to ‘fix’ it. So you both have to chart a path through the swamps of uncertainty together. That means you need share decisions and build mutual trust. You have to connect in a more substantial way.
To be sure, the world would be a better place if low back pain were as readily fixable as a broken sink. But it’s not, and until it is, we’ve been tasked with helping patients through the uncertainty. And we should appreciate the privilege!
So there you have it…
A rebrand of uncertainty. Five reasons to love it. Uncertainty is not just something we have to deal with or tolerate or manage. It’s something we should apprecite and enjoy. It helps us to learn, to grow as people, to think more rationally, to approach expertise and to connect with our patients. So jump in with both feet!
Til next time,
Tom
P.S. If you enjoyed this you might enjoy my post on being wrong.
P.P.S. If you want to jump into the uncertainty of cauda equina syndrome… why not buy our book? 😎
Great article! Linking to uncertainty and disagreement in clinical settings, with a focus on pain: the possibility of disagreement or uncertainty about pain in others reflects an indeterminacy, which is fundamental of our concept of pain. That indeterminacy in turn is due to social patterns of behaviour: our concept of pain must be flexible because pain behaviour, and our complex reactions to it, is diverse and unpredictable. Caregiving in pain settings can involve a threat to the caregiver and is conditional on the authenticity of manifest pain behaviour. As observers of pain behaviour, we are sensitive to signs of exaggeration, suppression, or malingering, in behavioural displays of pain. Accordingly, our concept of pain does not always connect behaviour, situation and personal experience, in a rigid way. Thoughts?
I'm busy reading Annie Duke's 'Thinking in bets' and she also talks about uncertainty a lot, although her framing is more neutral than positive or negative. Uncertainty just is, and her point is to try and understand it better.
I'm reading it mainly for some ideas on how to use probabilities to "deal with" uncertainty.
I'm really enjoying the book but I think you could probably get 60-70% of the big ideas from this interview with Shane Parrish - Getting Better by Being Wrong with Annie Duke: https://fs.blog/knowledge-project/annie-duke/