Certainty, Uncertainty, and How Patients Respond to Both

The Harvard Business Review recently presented an interview with Zakary Tomala, the author of a Stanford Business School study regarding certainty and uncertainty. The surprising finding? Experts are more persuasive when they’re less certain.

“The phenomenon at work here is what we call expectancy violations. People expect experts to be confident. Violations of that expectation surprise them. We see that in our data. Subjects reported being more surprised by the uncertain experts and the confident amateurs. A surprise draws you in and makes you pay more attention. It gives the review more impact.”

Tomala says that his study is one of the first to focus on “how one person’s certainty affects others.“ Although the study involved opinions about a restaurant, I started to wonder how the findings might apply to healthcare.

“When I went to the doctor, he said I was going to die in 3 months, and that was 2 years ago.” How many times have we heard this type of comment, one that seems to gloat at the failures of medical science? Growing up around religious people, I heard this a lot. At the time, I had feelings of relief and gratefulness when people I knew were able to beat the odds of their illnesses. But in the back of my mind, I wondered how a doctor would be able to claim such certainty. Or perhaps the patient misunderstood the doctor?

Medical training – mine, anyways – taught me that medicine is a lot grayer than we think. This was most clear in residency, and even more so when practicing. There are odds to everything. Expressing uncertainty as a physician can be difficult because patients today want to know things definitively. Most of the time, they come to us for answers, not opinions (even though a medical opinion is just that, albeit a very educated one, and often involves trial and error). Sometimes, we are pressed to answer questions that are impossible to answer with certainty. “How much longer do I have, doc?”

Perhaps part of the problem is that we shot ourselves in the foot when we had rapid advances in medical technology, which helped us diagnose and treat and make more of an impact on a person’s health. The perception of patients towards physicians and the self-perception of physicians themselves changed with the advances, as well. The we’ll-just-have-to-wait-and-see approach has been replaced by the let’s-get-to-the-bottom-of-this-ASAP approach. There is nothing wrong with this. We have benefitted more from these advances than the numbers can really tell us (think about loves ones treated for diseases that had dismal prognoses in the past).

Did American Healthcare get cocky? Did/do doctors presume that they had/have everything they needed to have the utmost certainty when treating a patient? In certain scenarios, if doctors project a particularly high level of confidence in a diagnosis or treatment and they are wrong, it can lead to distrust, doctor-shopping, and disjointed (read: expensive) care. There will always be cases where a patient found the diagnosis was in error and subsequently held that probably proficient doctor in lower regard.

I honestly do not know what goes on behind the closed doors of other doctor-patient evaluations. However, I do know that in my exam room words like “possibly,” “probably,” “I think”, “maybe,” “likely,” and “good chance” abound. I hope that’s what the patient hears, because that is the truth. Does that mean I am a bad doctor? Probably not.


2 thoughts on “Certainty, Uncertainty, and How Patients Respond to Both

  1. I could not agree with you more. I use the same terms/modifiers when I discuss prognosis, and I worry about docs who don’t. Since I see a lot of patients with FGIDs, I have to deal with “negative” tests quite often and spend a lot of the visit explaining the limitations of medical diagnostic testing, which is very difficult to get through to a patient with a chronic illness.

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