Uncertainty in the age of answers

Patrick Sullivan

Most people prefer certainty to uncertainty, especially in the context of their health. It is normal to want to have clear explanations for the way we feel. It is not uncommon for me to see patients with unexplained symptoms who are disappointed when their bloodwork or imaging test results are normal. Although of course they do not want serious problems to be found, people reach the point where they feel that any answer would be better than no answer at all. But while patients’ expectations about answers and certainty have changed with the times, doctors’ abilities to make clinical diagnoses with certainty are about the same as they were a generation or two ago—or maybe less than then, as we have come to rely more and more on tests for diagnosis.

Historically, doctors dealt with “unmasked” disease: dangerous problems with the body. In the Western world of the past, and in the developing world still, life was generally less comfortable; people went to the doctor if their symptoms surpassed their daily miseries. In a way, this situation made doctors’ work easier: their patients’ problems were, not uncommonly, textbook entities. As standards of living have improved, life has become more comfortable for many. Accordingly, medicine has moved from managing not only frank disease but also transient sensations and manifestations of not being at one’s best.

Western medicine is not well equipped to handle this shift. According to the disease or pathology model, only demonstrable, potentially life- or limb-threatening conditions are “real” diseases. The truth is, when someone has a headache for a few minutes, or a tiny spot on the skin, or mild discomfort in the belly, doctors working in the clinic truly cannot know with certainty what is causing it. Because of their very nature, these symptoms have not been investigated by medical science. The doctor’s job from the viewpoint of the traditional model is to sift through these symptoms, checking for any early presentation of an identifiable “serious” illness and providing general reassurance otherwise.

It is not that doctors know nothing in these scenarios; it is that all they have is a long list of possibilities—long to the point of being practically useless. A tiny spot on the skin could be a reaction to an allergen or an irritant or be a manifestation of one of various infections. Abdominal pain could be caused by acid reflux or lactose intolerance or constipation, or be an early signal of an ulcer or a tumour, or come on because the patient is having a big interview the next day, or ... etc. In the absence of red flags, the right course of action is to reassure, suggest comfort measures, and wait: most of the time, symptoms will pass. There might never be certainty about what was causing them before they go away.

And what about those without a “textbook” diagnosis who feel unwell and whose symptoms are not physical in origin: what should a good doctor do with those patients? These conditions can either be left undiagnosed, the patients’ issues referred back to the social world, or the symptoms can be massaged into a DSM box, as they often are.

Enter the information age. Everything is knowable. People are losing touch with the reality that although easy access to information makes it appear that everything can now be known with certainty, it cannot be. Having Googled the symptoms, generated a list of possibilities, and possibly arrived at his or her own favoured diagnosis, the patient goes for the doctor’s arbitration. Then the doctor says, “Hmmm. Abdominal pain, eh? Any fever or blood? No? Belly’s soft, I see. Well, eat a bland diet and hydrate for a few days; it should pass. Come back if it doesn’t, or if it gets worse.” From the doctor’s point of view, this is good solid medicine, or should be. But for some people these days, it seems unacceptable. How can a highly trained professional offer no more than Google does? What was the point of waiting, for that?

Sometimes it can help to take a broader approach to patients’ symptoms: what they mean for them in the larger contexts of their lives, what their underlying worries and challenges are. But this approach still does not provide an answer for a person focused on finding one. So again we have tests and more tests ordered, often with normal results that explain “nothing” about the symptoms, often resolved by then anyway. Or symptoms recur, frustratingly, episodically. Some people find benefit from different forms of health care in these scenarios, where practitioners offer other ways of naming symptoms.

There is no foreseeable resolution to this tension. People are busy and stressed, and they have bodily manifestations of their stress that trouble them. They live surrounded by information, so, understandably, they expect answers. The doctor offers uncertainty, and the advice to rest, hydrate, and try ibuprofen.

I do not have an answer for it, other than trying to work with people, reminding them that not everything can be known immediately and that their bodies seem okay in an essential sense, even though they do not feel well. Sometimes this works. Sometimes, we order the tests.