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Learning About Clinical Uncertainty

Wasfy, Jason H. MPhil

doi: 10.1097/01.ACM.0000242576.25803.65
Other Features: Teaching and Learning Moments

Mr. Wasfy is a fourth-year student, Harvard Medical School, Boston, Massachusetts.

I had just walked in the doorway. “I can't believe this is going to be all over,” Mrs. Smith said, and she walked up to me before I could say anything. “The doctor said that it's probably cancer, you know, the thing they found on the CAT scan,” she continued. Mrs. Smith was the wife of Mr. Smith, a patient I had admitted to the neurology service four days ago. Mr. Smith had a three-month history of memory loss and sharp personality changes. A mild-mannered, laid back businessman who ran a successful business for decades had developed into a dependent who never knew what day it was, rarely understood where he was, and was so anxious that he writhed back and forth in his hospital bed. This was his third hospital admission—and his wife wanted answers.

She started to cry. I still hadn't even said a word. “We've been going on like this for so long, and we finally are getting close to an answer. I'm sorry for being so emotional.”

“I understand,” I said back to her, “You've been down a long path, and anyone would feel like you do now. We're not sure that this finding is cancer, as you know. What I can promise you is that we'll do everything we can to get to the bottom of this.”

What struck me after our conversation was that the idea that her husband might have cancer in fact filled her with relief. Her tears were tears of relief, not tears of pain. I almost felt mad at Mrs. Smith.

I have thought about Mrs. Smith often in the few months that followed. With more clinical experience, I know now that I was wrong to think that Mrs. Smith should have felt differently. In a position of extreme uncertainty, when devastating diagnoses were always possible, she finally was able to grasp what had begun killing her husband. That uncertainty had been tearing her apart. She wasn't relieved about cancer. She was relieved because she could see an end to her uncertainty.

This episode and others like it over the course of my third year of medical school have been humbling. I have learned how difficult clinical uncertainty can be—not only for the patients, but for us medical students as well. As an undergraduate, I studied chemical and biomedical engineering, and I had become accustomed to clear, precise answers.

Medicine is different. During my first two years of medical school, our problem-based curriculum showed me that medicine would not prove as precise as my undergraduate studies. But at least in the classroom cases, the diagnosis was clear. Over the course of my third year, by contrast, I have had to accept cases in which patients are discharged without a clear diagnosis. That uncertainty is unsatisfying for doctors, and disconcerting for patients.

Two of the hardest lessons I have learned over the course of this past year, therefore, are first that clinical answers are not always clear, and that dealing with a system as complex as the human body necessitates a lack of precise understanding. More crucially, I have begun to confront how that uncertainty can take a toll on patients. Before I started medical school, I had thought that nothing must be more devastating to a patient than a crippling diagnosis. Now I know that for many patients, the uncertainty of not knowing can prove far more frustrating. Mrs. Smith and I have both learned that lesson the hard way. It has been one of my toughest lessons in medical school—but I will be a better doctor for it.

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Some identifying details have been changed to protect patient confidentiality.

Jason H. Wasfy, MPhil

Mr. Wasfy is a fourth-year student, Harvard Medical School, Boston, Massachusetts.

© 2006 Association of American Medical Colleges