In this section, we present brief sketches of extremely uncertainty-tolerant and uncertainty-intolerant physicians. We are not making empirical claims about any actual practitioners. Tolerance and intolerance for uncertainty are not binary; a physician’s comfort with incomplete information is best measured on a spectrum. Indeed, it fluctuates from patient to patient. The following is meant merely as a thought exercise—a philosophical exploration of extremes that can help us to clarify the real-life virtue and wisdom that lies between the two poles. In employing this argumentative structure, made famous by Aristotle in his work on the virtues,24 we are not suggesting that either sketch represents a mode of actual medical practice. Rather, we are aiming to give readers a clearer sense of the most dramatic expressions of two sorts of dispositions, as well as their benefits and dangers. Ultimately, searching for a mean between these two extremes will help illuminate possible pitfalls both tolerant and intolerant practitioners face and to sharpen our thinking about how we might teach our students and residents to sidestep them.
THE UNCERTAINTY-TOLERANT CLINICIAN
Imagine an extremely uncertainty-tolerant physician. How might such a practitioner respond in the face of uncertainty? This philosophical exercise admits more than one kind of answer, of course, but consider the following sketch:
First, extremely tolerant physicians would be likely to perceive the limitations of their knowledge. Because they are comfortable with incomplete information, they will not distort the facts of the case to make them fit patterns they better understand.
Second, extremely tolerant physicians would feel comfortable proceeding in the face of uncertainty without panicking or feeling burdened or bothered by gaps in their understandings.
As a result, third, they would be likely to be honest with their patients about what they did not know. They would feel no need to hide or compensate for their lack of knowledge, and this openness could help to promote communication and trust between them and their patients. This disposition may make it easy for them to meet their obligations of honesty when interacting with patients and families.
Fourth, extremely tolerant physicians, not fearing what is unknown or poorly understood, would not be afraid to confront new problems and challenges they did not fully grasp. While they would not shy away from the unknown out of fear, this does not mean that they would always engage with new problems.
At this point, it may seem that such physicians would be paragons of virtue. And indeed, we ought to encourage young doctors to be honest about the limits of their knowledge,22,25 develop strong interpersonal skills, be honest and forthcoming in their interactions with patients,23,26 and not shy away from new challenges. Unfortunately, the portrait of the extremely uncertainty-tolerant physician has some less attractive features as well.
Fifth, people who tolerate uncertainty might lapse into a contented stagnation that results in poor practice. Recall that comfort with uncertainty is characterized by confidence in one’s ability to act (or not act) in the face of one’s subjective recognition of incomplete information. In the extreme, such a disposition could result in careless, lazy, and ill-considered behavior: those who are too comfortable with incomplete information may be tempted to proceed when they should not.
Relatedly, sixth, extremely tolerant physicians may be less likely to ask for help from more experienced or knowledgeable colleagues. Such providers would not be ashamed to admit their lack of knowledge, but when one is totally at peace with one’s ignorance, seeking assistance can seem like a waste of time and energy, and an unnecessary imposition on others. This might be especially true in a busy practice or hospital with harried colleagues.
Seventh, tolerant physicians might be unmotivated to dig deeply into medical scholarship to learn more about the symptoms and conditions that generated uncertainty. While less tolerant physicians’ gnawing anxieties might drive them to consult colleagues and journals, their extremely tolerant counterparts may be content to take their best guesses and move on, especially if pressed for time.
THE UNCERTAINTY-INTOLERANT CLINICIAN
What about an extremely uncertainty-intolerant physician whose tolerance for, and comfort with, uncertainty is extremely low? What sorts of attitudes and dispositions might we expect from such a practitioner?
First, where the tolerant physicians’ comfort with uncertainty allowed them to recognize and accept elements of a case that outstripped their understandings, intolerant physicians may be disposed to simplify or mischaracterize confounding data in order to avoid the discomfort that attends their perceptions of uncertainty. The failure here is a kind of distorted perception: because of their anxiety, they (perhaps unconsciously) protect themselves from uncertain situations by representing them as more straightforward or familiar than they really are, raising the problem of premature closure in the diagnostic process.27
Supposing intolerant physicians are able to perceive their situations accurately, they may, second, be hesitant to act. At the limit, such practitioners may feel paralyzed by their lack of knowledge, unable to proceed in foggy conditions.
Third, intolerant physicians may be less than fully forthcoming and honest with patients. Unlike tolerant physicians, who feel no need to hide or compensate for their lack of knowledge, intolerant physicians may be tempted to present patients with half-truths or keep communication to a minimum until their cases become clearer.28
Fourth, intolerant physicians may shy away from new challenges, or even new data, that would lead to uncertainty and therefore cause anxiety. In the most extreme cases, this disposition could manifest itself in outright avoidance of new information.
Despite these disturbing flaws, there are elements of extremely intolerant clinicians’ professional outlook that we may admire, at least to some extent.
Fifth, intolerant physicians (again assuming they could correctly perceive that the situation exceeded the limits of their understanding) would not be complacent about their lack of knowledge. Unlike extremely tolerant physicians, intolerant clinicians would be especially thorough and deeply concerned to do their best to act safely.
Along the same lines, sixth, the intolerant physicians’ unwillingness to act when unsure of themselves might make them more likely to ask for help from more experienced and knowledgeable colleagues.
Seventh, intolerant physicians, motivated to ease their anxiety and discomfort, may go “above and beyond” to educate themselves in response to, or in preparation for, uncertain clinical situations. Indeed, their perceptions of their own incomplete understandings could push them to become highly knowledgeable and diligent caregivers, or even drive them to make scientific discoveries.