Sunday, March 14, 2021

Tolerating Uncertainty in Medicine

Uncertainty makes everyone anxious, although each of us has a unique threshold for uncertainty tolerance.  In other words, different folks may react quite differently if they are confronted with the same set of facts. 

Consider this hypothetical.  Two patients who are of similar age and enjoy excellent health undergo a CAT scan for a stomach ache.  By the time they follow-up with their physicians to review the results, their symptoms have resolved and they feel perfectly well.  A small spot is seen in the liver which the radiologist suspects is an innocent cyst, but he cannot state this definitively.  Each of the patient’s physicians explain that minor accidental findings like this are common and are very unlikely to pose any health threat.

Patient #1: “Ok, doc. I feel great and if you’re not worried, neither am I.”

Patient #2:  “Are you sure it couldn’t be serious, like a cancer?  Should I have it cut out just to be safe?”

First of all, let me give readers an inside tip on how to pose inquiries to your doctors.  If you begin your question with,  “Doctor, are you sure that…”, the physician’s response will be, “No, I can’t be 100% sure…”  If you begin your inquiry with, “Doctor, is is possible that…”, your doctor will answer, “Yes, anything is possible…”

Life is a casino.  We play the odds every day.

There are no guarantees in medicine or in life.  Uncertainty is everywhere and we all have our own uncertainty tolerance levels.  While there is no correct uncertainty threshold, your own level will determine if you spend most of your time at peace or on edge.  If you demand certainty, for example, then you will be forever seeking more testing and evaluation to eliminate doubt, and you may never reach your destination.  This principle may also apply when making investment choices , considering legal advice, buying a used car, eating street food abroad, considering an extended warrantee on an appliance as well as choosing among medical treatment options.   If I reassure a patient that his colonoscopy is normal and published data suggest that the chance that a lesion was missed is about 5%, will the patient accept the test’s inborn imperfections?  Will I?  Should everyone undergo 2 colonoscopies in order to decrease the miss rate?  How much effort and resources are worth achieving small incremental benefits?  I’m only posing the question here.

And individuals who have excessive risk tolerance may risk unfortunate outcomes.  Cashing in retirement funds for chips to place on the roulette wheel would make most folks uncomfortable. 

A patient I saw recently is eligible to receive the COVID-19 vaccine but does not wish to proceed.  He is aware of the safety and efficacy data but is concerned over potentially unknown adverse reactions that may emerge over time. This is not a right or wrong issue; it’s a matter of judgement.  He isn’t certain that he his making the right choice, but he is certain which option feels more comfortable at present.  Many others would decry his decision as a risky roll of the dice.  Remember, however, we’re all gamblers as we journey through life placing our daily bets and hoping at least most of them pay off.  


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