The Art and Solace of Uncertainty

The Art and Solace of Uncertainty

David Katz 14/12/2020
The Art and Solace of Uncertainty

Many times over the years I’ve been asked to recommend a physician, or more generically- asked what to look for in a physician.

Much might be said, but I always prioritize the same thing. In medicine, what I most want to hear a colleague say at least once before I know I can trust her/him- especially with the clinical care of me or someone I love, is: I don’t know. I’m not sure. I want them to know how to proceed confidently despite that uncertainty, of course- that’s expertise, and it matters. Functioning effectively in a realm of greater or lesser doubt is every clinician’s constant challenge- but I want to know the doubt is recognized and respected.

This may seem a low bar, but it’s not. Humans, asked to be expert, seem to feel a need to renounce the native fallibilities of our kind. This is misguided nonsense of course; experts remain fallible, and expertise matters not despite uncertainty, but because of it. But the tendency to deny seemingly prevails

It prevails perhaps especially in medicine because historically, our training shames us for our uncertainties - although for all I know some other professions may make similar mistakes. Ward rounds - visiting hospitalized patients as a roving troop, overseen by the senior physician or attending- are a medical rite of passage. The attending’s unstated job is to display erudition by asking questions the junior physicians can’t answer, and then shame and humiliate them for that unacceptable display of feckless ineptitude.

I am proud to say I opposed this self-perpetuating abuse in my own practice as the attending, and as a residency director working to expunge such abuses from the system. I certainly experienced the abuse as student, intern, and resident. It is improving over the years, like the abuses of fraternity hazings- but like those, it recurs nearly everywhere not under constant scrutiny- rather like mildew.

Let’s be clear: no human knows everything with certainty all the time, no matter their potency of mind, acuity of insight, or cultivated expertise. Not Newton or Einstein; Hawking or Hippocrates; Osler, or Oprah. Nobody. To err is more than merely human; it is the universal condition of mortal existence. We are not omniscient, do our best, and get things wrong.

Yet, among the many grave liabilities of our now years-long descent into fierce cultural division, the extremes of partisan opposition, the amplifying distortions of Internet Echo chambers- is the semblance of certainty everywhere, all the time

I am lobbied daily by those who tell me- don’t suggest, but just flat out tell me- that masks are useless against COVID19. I am also lobbied daily by others who tell me masks reliably, categorically protect wearer and non-wearer, that they are, in effect, THE remedy. Some of them are selling masks, but many are not.

I am lobbied about the miraculous effects against COVID of various drugs and supplements, also daily; and also daily, receive a commensurate barrage opposing all those same treatments as unsubstantiated folly.

I am told as well all about the evidence supporting any given argument. Again, I am not given suggestions or proposals or invited to reflect. I am generally told exactly what evidence there is or isn’t, how reliable it is or isn’t, and exactly why any claims to the contrary are deluded. I can assent and be right, or dissent and be wrong. Debate is inadmissible.

My own credentials in adjudicating evidence are generally not invited, apparently deemed irrelevant. Hard won expertise, years of experience, or for that matter facts offer no defense whatever against lectures, often by people who have never worked in science, regarding exactly what evidence there is and isn’t, and exactly what it all means.

This has been the unheralded calamity of the pandemic, and shows all signs of remaining so. This far into our extreme humbling by COVID19, we are still a fractious horde of opposing hordes, all making noise, all disinclined to heed any common signal.

The immediate nidus of just such turbulence is the COVID vaccine. The vaccine can be vastly safer than taking chances with the virus without being a panacea. The vaccine can do great amounts of net good even if occasionally doing harm. Vaccine advocacy would be far more effective if it preemptively allowed for the likely deficiencies, and made the case for net benefit despite them. The case for uptake of vaccines wins despite plausible doubts, not by veiling them. Opposition should yield to transparency, data, and persuasion.   

We might even note that science must at times follow where sense leads. As it catches up, it may corroborate or challenge, and we should be prepared for either. But action now- about vaccines, or masks, or medications- can only be predicated on what we know now, and our best, expert interpretation of it.

Personally, I think we would all trust one another a whole lot more if the case for any given action emphasized the sense it makes despite the doubts, intrinsic dangers, or want of data. 

To the best of my knowledge, everyone has been wrong about the pandemic- not only those who were flamboyantly wrong, but even those who were most flagrantly right. Pandemic experts and the CDC opposed mask use, before espousing it. Medications were touted as miraculous before studies suggested them to be of dubious effect. Errors were made about the likely toll of the pandemic in both directions. New Zealand may have locked down too much even if Sweden locked down too little. In my own case, I was emphatically wrong about the pandemic timeline.

The seduction of unfounded certainty is pernicious, and insidious. It contaminates everything. The news we hear about COVID, for instance, is stripped of context presumably to make it “pop.” So, we hear about COVID deaths, but not about average mortality with no pandemic (i.e., roughly 8,000 deaths from miscellaneous causes daily in the United States). The deaths from COVID are tragic, but the pretense that no one would be dying otherwise implies advocacy where reporting ought to be. We are told about hospitals and ICUs filling up, and in some cases, that is a genuinely acute and pandemic-specific crisis. But we are again given no context: hospital census always goes up this time of year, and I have seen “capacity” reached many times over the span of my 30-year clinical career, no pandemic required. Is it that we, the public, are not trusted with the whole truth?

That’s my impression, and I consider it dangerous. The whole truth, encumbered by uncertainty, invites consideration, reflection, and judgment. Partial truth, devoid of context, looks like what it is- a sales pitch. That invites one of two opposing actions: buy it, or don’t buy it. Sound like anyone you know?

Our public health policy need not be heavy handed to be highly effective. We could empower people to make some choices for themselves. I offer “hierarchical responsibility” as an expression of this approach: mandate what must be mandated; guide where guidance is required; invite and encourage where that suffices. The more we are drawn into the toxic ramifications of expostulating certainties at one another, the more we retain the inclination to resent the same at the receiving end. People are far more apt to resent being told what to do, than being told what’s what- doubts and all.

I would never trust a doctor who can’t say “I don’t know.” In fact, if you encounter one of those, I recommend you run like hell in the other direction before they do anything irreparable to you.

Why, then, should any of us trust opposing certainties from left and right as we make our way through the greatest public health crisis in living memory? It seems we don’t, and much of our dysfunction may reside there.

Medicine has long been catalogued as art and science, and rightly so. The art resides in translating science to the optimal care and maximal advantage of any given individual. This is no generic art, but the very particular practice of it propounded by Aristotle in his Poetics: an eye for resemblances.

There is uncertainty in science, but all the more so in art, and the eyes that seek and behold essential resemblances. Science informs us, but never perfectly- for it is imperfect itself, in a permanent state of evolution to something better. Evidence of absence may tell us decisively what doesn’t work, but absence of evidence only ever tells us what we don’t yet know.

Consider how much more constructively and adeptly we would have optimized resources during the pandemic if all concerned had not lobbied and advocated for their favored view predicated on false certainties, but rather considered and conceded all pros and cons and doubts about both- for masks and lockdowns, hydroxychloroquine and herd immunity, ventilators and remdesivir, ivermectin and immunosurveillance. Buffeted by the roiling currents of our acute divisions, we mostly assaulted one another with unwarranted certainties, and amplified the divide each time.

I think much is already clear about how better to manage a pandemic by better managing ourselves and our interactions with one another. Much won’t be fully clear about how best to have managed this pandemic until hindsight makes it so, if then. But salient among the lessons already clear is the value of humility, the concession of doubt. Doubt is not capitulation. Doubt is real and honest and inevitable, and thus reassuring. Doubt, in the context of thoughtful consideration and applied expertise, is an invitation displacing a provocation. The uncertain can be both helpful, and helped- the certain can only be heeded.

Heeding is not a popular vocation. So, instead, we either champion the same certainty if we happen to favor it, too, or oppose it just as ardently. The critical advantages of common cause on ground common to the differently disposed, thoughtfully uncertain, yet willing to listen and learn- are sacrificed on the altar of our obstinate vanities.

The abiding lesson of the pandemic is: humility.

Give me counsel that accommodates doubt. Give me perspective that allows for both right and wrong to both right and left. Give me reasons without hyperbole, data without drama. Whenever you can, tell me what you think is what, without telling me what you know I must do. 

Give me the art of your considered uncertainties, informed by science- and I will find solace in it. I will trust more; I will listen longer; and given those, there’s a good chance- we may proceed together.

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David Katz

Healthcare Expert

David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.

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