Tolerating Uncertainty in Medicine

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Patients regularly initiate inquiries starting with, ‘could it be…’   This usually follows my opinion on their symptoms and the available diagnostic or therapeutic options.  Patients have often conducted their own research, generally on the internet, or have received diagnostic advice from folks they know who have suffered similar symptoms.  It’s perfectly natural, for example, if a patient’s roommate had his gallbladder removed for the same stomach issues, that the patient may believe that his gallbladder needs to be donated to science also.  (Note to reader:  just because the roommate underwent gallbladder removal doesn’t necessarily mean that this was the correct treatment.  In a perfect medical world, every operation would cure the illness.)

Consider a 22-yr-old female who sees me with some mild abdominal cramping and bowel issues, which are long-standing.  There are no medical 'red flag' signs present.  I have taken a thorough medical history.  I suggest to her that it is likely that she is suffering from a case of irritable bowel syndrome, an extremely common condition that is highly compatible with her issues.   Note that I used the word likely, not definitely in my phrasing.  Physicians are cautious not to convey complete certainty. 

Here are some potential inquiries this patient may direct to me.

Could it be a parasite

Could it be Crohn’s disease?

Could it be a gluten issue?

Could it be a food allergy?

Could it be the pancreatic condition EPI, which I saw on a television commercial?

Could it be my thyroid?

Could it be my medications?

If you ask us, could it be…, then we will respond that anything is possible or that your suggestion is unlikely, but we won’t reject your suggestion out of hand.  We physicians, have been wrong too many times to be dismissive of views that differ from our own.  Indeed, practicing medicine is a very humbling experience.  And, patients and physicians will have to tolerate uncertainty and may need to negotiate if further testing to reduce it is worth it.  And, to add another wrinkle to the issue, sometimes the test results are wrong.  We’ve all heard examples of individuals who passed a stress test who soon afterwards suffered a cardiac event. 

Adult Tapeworm

"I've lost weight.  Could it be a tapeworm?"

So what should the patient’s goal be?  There is no single correct approach.  It depends upon the philosophies of the patient and the physician, the tolerance level of uncertainty and the potential medical risks suggested by the symptoms.  Obviously, I will be more aggressive in advising a patient with unexplained weight loss than I will with someone with uncomplicated heartburn.

Your symptoms may be compatible with multiple diagnoses.  Or your condition may be evolving and may not yet be recognizable.  Or you may truly have a rare condition.  If you scan the internet for causes of abdominal pain, there may be in excess of a hundred possibilities.  Should you and your doctor aim to go through this list?

If you are seeing your doctor with a fever, and you ask could it be malaria, expect to hear your physician respond, unlikely!