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.
I think.....I think this is getting to the very core of why Primary Care is in the trouble it is in. Yes, there are many factors - organization, payment systems, administrative burdens, clinical guidelines that make no sense for the patient's well-being, the destruction in front of our eyes of the "patient-physician relationship", the increasing sense of entitlement and decreasing sense of "duty" and "work" etc. etc - but the unwillingness to make and be accountable alone for a decision, the "grasping of the nettle", valuing the trust of a patient is surely a fundamental cause of the mess Primary Care finds itself in these days.
I remember very well during my medical education at McGill that all the "disagreeable" work - talking to patient and their families, announcing a death and asking for an autopsy, digging up lab reports, talking to radiologists for a differential diagnosis - were called "scut work". And Primary Care is scut work, heavily accountable at the deepest individual level. . Nobody in the right medical mind would want to do that all their carreer, right?. How much better, if and only if one must, work only in teams?
I have more thoughts for a later time, but keep digging, Dr Duvefelt.
Thank you. Absoulutely at the foundation of care.