The Anatomy of Uncertainty

Chapter 3 describes the anatomy of medical uncertainty, identifying key attributes that give it a three-dimensional conceptual shape, form, and structure. It characterizes uncertainty in terms of its (1) fundamental sources (root causes), (2) issues (substantive problems), and (3) loci (persons in whose minds uncertainty resides) and presents a conceptual framework that allows the variety of uncertainties in medicine to be classified and better understood. The chapter makes the case that in all of these ways, a three-dimensional conceptual framework can facilitate a more intentional, targeted, and rational approach to evaluating medical uncertainty. By providing a way of visualizing, ordering, and objectifying an otherwise invisible, disordered, subjective reality, the framework can ultimately enable clinicians and patients to better manage medical uncertainty.

The Management of Uncertainty

Chapter 5 presents an approach to managing uncertainty in medicine. It develops the idea of “uncertainty tolerance” as a normative goal for efforts to manage uncertainty. It offers a working definition of uncertainty tolerance as an optimal, adaptive balance in people’s responses to uncertainty and identifies humility, flexibility, and courage as key moral virtues or capacities that enable uncertainty tolerance. The chapter presents a practical integrative framework of uncertainty management that aims to promote uncertainty tolerance through four key tasks: establishing the diagnosis of uncertainty, assessing its prognosis, clarifying goals, and initiating treatment. The chapter uses a case study to explore the potential practical value of the framework in helping clinicians and patients to manage and tolerate the uncertainties they experience.

A Way Forward

Chapter 6 concludes the book by offering a vision for how to promote uncertainty tolerance in medicine. It identifies various system-level strategies, spanning medical care, education, and research, that can foster humility, flexibility, and courage and thereby help build uncertainty tolerance into the structures and processes of healthcare. The chapter examines how these processes can ultimately enable uncertainty tolerance to become part of both the worldview of individual clinicians and patients, and the overarching culture of medicine. The chapter makes the case that uncertainty tolerance in medicine ultimately requires the adoption of a worldview that affirms the necessity and value of uncertainty, and enables us to transcend it.

Introduction

Chapter 1 introduces the topic of medical uncertainty and discusses its importance in human life. It argues that medical uncertainty is a critically important but historically neglected experience of both clinicians and patients, and that the COVID-19 pandemic and other recent events have raised the need to better understand and manage this uncertainty. The chapter makes the case for the value of a conceptual framework in helping clinicians and patients to better understand, manage, and ultimately tolerate the uncertainties they experience and provides an overview of the book. A conceptual framework alone cannot change reality, the chapter argues, but it can help clinicians and patients to adapt to it.

The Nature and Etiology of Uncertainty

Chapter 2 examines the nature and etiology of uncertainty in medicine. It reviews existing conceptions of uncertainty and demonstrates the diversity of ways in which it has been defined, both in and outside of medicine. It describes the meaning and functions of metacognition, and offers a working definition of uncertainty as the metacognitive awareness of ignorance. Referencing various insights from the social science literature, the chapter describes how uncertainty as a more general phenomenon is both psychologically generated by novelty, discrepancy, and deliberation and socially constructed and transmitted through the exchange of information.

The Natural History of Uncertainty

Chapter 4 describes the natural history of medical uncertainty—that is, the way that the phenomenon is manifest in people’s lives. It classifies people’s psychological responses to uncertainty within two main categories: primary (initial cognitive, emotional, and behavioral responses) and secondary (compensatory responses aimed at regulating primary responses). It presents a conceptual framework that classifies the variety of primary and secondary responses to uncertainty and discusses how the framework can help clinicians and patients evaluate and manage these responses. The ultimate goal of this framework is practical: to improve the management of uncertainty in medicine. The framework can promote this goal by enabling clinicians and patients to rise above their own regulatory responses to uncertainty and achieve greater tertiary control over them.