It was the summer after freshman year. The air, sticky-sweet and salted with possibility, reminded me of a future yet to come. That July evening, my friend and I found ourselves crowded into an indoor batting cage, which served as a temporary concert space, illuminated by a few string lights. As I peered into the dark batting cages, I couldn’t help but feel as if I was looking into an abyss. The wispy nets seemed to never end and melted into the wall, an image that for some reason left me unsettled.
At the moment, I did not know why, but I distinctly remember a shudder passing through me as I attempted to make out the “end” of the batting cage. As someone who lived her life in adherence to structure and absolutes, the ambiguity struck a chord, and although I would have liked to believe it was a one-off occurrence, I would be lying. Humans, after all, are primed for pattern-recognition, dividing a shifting landscape of sensations into dorsal and ventral streams of information, using heuristics to make predictable snap judgements, digesting chaos into something a little more palatable. To say that we are inherently comfortable with uncertainty would be false, one in direct conflict with our biological need for security. Even our memories, which play a role in learning and survival, ensure that our environment doesn’t constantly shock us with novelty and instead breeds a level of familiarity and comfort. And, when we don’t know the future, which we often don’t, we turn to our past, tending to our scars which bear such reminders.
If there is a field with the greatest aversion to this fundamental human aversion to chaos, it would be medicine. From organic chemistry to statistics to the MCAT, our pre-medical curriculum and standardized testing prioritizes accuracy and distills the world into A-E answer choices. Taking difficult, ambiguous classes which may harm our GPA is advised against with well-meaning guidance counselors nudging us towards courses which demonstrate “mastery.” Even our pre-clinical exams operate under this framework, reducing patient cases and diseases into bite-sized pieces. Of course, not all of this is counterproductive. Building a solid base of knowledge and fostering confidence requires simplification and a thorough understanding of what is known. And it is our discomfort with uncertainty that fuels scientific research, helping to elucidate complex signaling pathways and more efficacious treatment regimens. Our desire for knowledge has enabled human exploration and survival, yet our inability to deal with or accept present ambiguities continues to serve as our downfall.
If there is one thing that I have learned throughout medical school, it is just how much we do not know. Medicine still gropes through the dark, grasping at answers, for anything that can begin to explain the tangled, intricate mess that is the human body. Even though we’ve gone a long way from humorism, blood-letting, and the miasma theory, many of us are still plagued by the persistence of incurable, chronic conditions, rare genetic disorders, and even pandemics. COVID-19 brought the world to a stand still, prompting health systems and public health officials to scramble to come up with policies to address a virus that was still poorly understood. I know from conversations with neighbors, classmates, and family members, that the constantly shifting policies regarding masking, isolation and quarantine protocols, and treatment regimens eroded the public’s trust in medicine.
Part of it is due to the fact that medicine still donned a mask of certainty in the name of ensuring that individuals would abide by rules and regulations during a pandemic of a novel virus. Although it’s more than understandable, failing to admit to our lapses in understanding and communicating transparently about why certain decisions were made only led to more confusion. Eroding the varnish of complete certitude is painful; it forces us to come to terms with something that we’ve been so desperately trying to run away from. But if we ourselves can’t tolerate it, how can we expect our patients – NICU babies attached to ventilators, teenagers with glioblastomas, individuals in hospice suffering from end stage renal disease — to navigate the ambiguity that comes with their diagnoses? But, more importantly, how can we expect ourselves to guide them through gray matters if we haven’t come to terms with it as well?
These are the sorts of questions that linger in mind after hearing from families during Law Auditorium patient panels, reading the Washington Post’s Medical Mysteries series, or sitting across from my LEAPP patient as she recounts her latest emergency hospital stay. Life is difficult and complex and downright messy, and to say or believe otherwise is a form of deep cognitive dissonance. In fact, inadequacy to cope with or accept medical uncertainty has been associated with distress amongst medical trainees, even contributing to negative attitudes towards the underserved whose ailments are infinitely more difficult and nuanced to “resolve.” Moreover, intolerance of uncertainty has been linked to excessive diagnostic testing and over-prescribing and a hesitancy to admit to lapses in judgements or even mistakes, resulting in significant distress and harm to patients. Physicians themselves are also at a greater risk for burnout and decreased job satisfaction. Accepting uncertainty is more than a philosophical curiosity; it is necessary if we wish to ensure the well-being of both our patients and ourselves.
Such realizations have prompted the introduction of coping strategies as a core clinical competency, and it starts with shifting how we frame the role of medicine. As Steven Hatch expertly describes, “Part of the reason why the culture of medicine prizes certainty is people come to expect it in us.” Patients arrive at our offices and wards awaiting a diagnosis and hopefully a cure. But more than 20% of them will be misdiagnosed and many will remain undiagnosed, hopping from doctor to doctor in the search for relief. What if instead of behaving as “solvers,” we leaned into our vocation as “healers,” shifting the language surrounding diagnosis-less appointments from one of failure to one of possibility? Only when we realize that healing can take place even outside of the confines of results and treatment protocols can we truly sit with our patients and hear them and their pain. Our skills as compassionate active listeners is our most prized asset as well as our ability to be honest, to be vulnerably human in the presence of another. It’s the only way to ensure that when we explain to a patient that we do not know what disease they have or how to treat them, that they know that we are not abandoning them – and that it merely means another kind of door has opened.
The kind of door where shared decision making and transparency are at the forefront. Many medical schools are working on teaching students how to communicate ambiguities in care, explain statistical errors in prognostic values, and evaluate risks with not for their patients. Although there is much to be improved on at Penn, learning about respecting patient autonomy, active listening, and decision-making science in Doctoring and our courses has started the conversation about how our patients may evaluate risks and benefits differently and how our job is to merely assist, not determine, their journeys. By communicating honestly and humbly, we can cultivate trust and become devoted to the art of healing, viewing uncertainty as an opportunity to get to know more about our patients, their values and how they choose to respond to the complexities of life.
Such ideas remind me of an encounter with a diabetic patient in Guatemala. Although I was merely tasked with conducting an interview about her experience with a community health program, the conversation quickly turned into a heart-wrenching description of her life from witnessing the murder of her father to being horrifically abused by her mother and her husband to being abandoned by her kids. All alone and living in dire conditions, she carried deep pain in her eyes. But when she proclaimed that sharing her story and knowing that someone cared enough to listen made her feel better, I was deeply humbled. At first, I felt ashamed – ashamed because here I was holding her pain without any ability to cure or treat her. But upon hearing her statement, I realized that listening and story-telling is therapeutic in itself. It is often all we can offer when conventional treatments do not exist.
It is my greatest hope that medicine can begin to move towards an environment of acceptance. Viewing uncertainty not with disdain but with unfettered curiosity, obtaining knowledge through scientific inquiry but also through our patients. By listening to those who seek our care and respecting their variable life journeys, we can fully adopt our roles as “healers” and communicate transparently about present ambiguities. Only when we become vulnerable and human in the eyes of our patients can we begin to view them similarly as well. Medicine, after all, is a rich store for exploration of the human condition. But only if we let ourselves dive deep into the gray and transform dark batting cages from frightening abysses into horizons of possibility.
Heta Patel is an MS1 at the Perelman School of Medicine.
Image by Grace Wu, an MS1 at the Perelman School of Medicine.
