Power to be uncertain

I keep reading that language matters. I agree, so I want to write about ‘medical uncertainty’.

I’ve been on Twitter for well over a year, following many medics, and one of the topics that systematically reappears in my timeline is medical uncertainty. And so, medics and researchers, tell the world that medical profession and uncertainty are inseparable. Doctors must espouse and cope with it. The issue is so important that the Royal College of GPs has a book about it.

Now, I’ve had a look at all instances of the word ‘uncertain’ in the first chapter of the book (it’s available to download) and I was probably not particularly surprised to find out that none referred to a clinician who is uncertain. And that’s my problem in a nutshell. As you, medics, talk about ‘medical uncertainty’, you talk about it as if it were a thing, an object out there which needs to be described, assessed, ideally, I guess, measured. Indeed, I am yet to see a doctor saying something like:

I am uncertain.

For, you see, there is no ‘medical uncertainty’. It is people who are uncertain. I’d even go further than that – how about saying:

I am uncertain about what is wrong with you.

Perhaps even:

I don’t know what is wrong with you.

It does changes the perspective, doesn’t it? We no longer talk about the abstract ‘uncertainty’, but we talk about a John or a Mary who is uncertain about something in a conversation (consultation if you like) with, shall we say, me.

Let’s be clear. Yes, of course, I would be unhappy to hear this – who wants an uncertain doctor? Yet, I would also hope that after telling me that you are uncertain, you would also explain to me what you are going to do about this uncertainty. You see, I prefer this because when you admit uncertainty reinforces trust between us (apparently, I am in minority, though, see below).

And so, by talking about ‘medical uncertainty’, rather than uncertain people, you construct uncertainty as…. a symptom. For me it is striking how it resembles the hundreds of symptoms/diagnostic criteria in the diagnostic manuals. And just like in them, you seem not to focus on people’s experience, but on ‘medical uncertainty’, as if it could be abstracted from the context of an interaction of a real medic with a real patient. So, once again, there is no ‘medical uncertainty’, there are people who are uncertain, here and now, facing a real person, who doesn’t have some abstract ‘symptoms’, but suffers, comes for help or whatever else.

Now, why do you talk about ‘medical uncertainty’, rather than about uncertain people? Well, the first answer would be that in medicine, just like in the diagnostic manuals, you prefer focusing on things, objective ready to be inspected, measured, assessed and, ideally, cured. That’s the dominant paradigm of medicine, for me best rendered by the sentence I wrote about a couple of times:

So, the evidence is….

There is no ‘narrative’, no experience. The evidence is on the computer screen not in my experience. But there is more here, I think.

In a blog on medical power, Jonathon Tomlinson writes:

We can force patients to stay in hospital under the mental health act and force them to have treatment. Our professional opinion in law and in politics carries significant influence. We also have social or structural power because we tend to be wealthier, healthier, better educated, more articulate and more socially connected our patients. Because our power is also due to the underlying structure of society, forty years of widening social inequalities have augmented medical power at the same time as dis-empowering the majority of our patients. Whenever we speak we are exercising power.

Yes, whenever you speak, you exercise power. And here, I think, is the bottom line. If you want to ‘speak power’, you can’t really speak of ‘uncertain doctors’, you must speak of medical uncertainty, as if it didn’t apply to anyone in particular. In the same way, you cannot really tell me you are uncertain.

Unfortunately, however, things get complicated here. A few years ago, I went to see my GP about something. The ‘something’ was easily treatable with some medication. But I wasn’t sure whether the GP remembered that I was on statins (I’m still on statins, despite the controversies – I wish someone told me what to do). And so, I asked my GP and, surprisingly, he looked uncomfortable. The silence that fell was intense, but after a few moments he reached for a big book, leafed through it and said taking the medication he was prescribing was OK.

I would not have been me, if I hadn’t commented on it. And so, I thanked him for acknowledging his uncertainty. His response was startling:

I knew YOU would understand.

stressing, the ‘you’. I looked at him in disbelief. Yes, I said, of course, I understand, you can’t be expected to remember everything. This is what the big books are for. To which he said something like:

You would be surprised what our patients expect from us.

And here I understood something. The power with which you talk comes, at least partly, from us. We want you to speak to us as if you were omniscient, all-powerful and all-wonderful.

But I want to end with a comment on language. Language matters and Twitter even has a hashtag on this. I keep saying that yes, language matters, but let’s not get carried away with it. Just because language matters, it doesn’t cancel reality. A kidney remains to be a kidney, as I wrote some time ago.

There is more, though. I would like to ask all those ‘languagematters’ people who actually decides what matters. Which language matters? You see, I happen to think that medics should not speak or write about medical uncertainty. I think it hides a very important aspect of medical encounters – doctors can be uncertain. And yet, there is no campaign to stop using the phrase, there is no campaign to get doctors to own up to their uncertainty. Why? I don’t know. I do know, however, that it’s also about power, but not medical. And perhaps there is a blog (and much more) in describing this other power. It can be very powerful.


  1. There is another, third way to think about uncertainty in medicine.

    Jerome Groopman one of the most insightful doctors writing about the realities of medicine and the role of clinicians sees uncertainty as a source of hope.

    Groopman, a pioneering haematologist and oncologist, is very outspoken about how his personal experience of suffering has shaped his practice as a medic caring for terminally ill patients.

    In The Anatomy of Hope (2005) he describes his maturing as a doctor from enthusiastic young know-it-all to mature physician grappling with his own limitations–a book every healthcare professional and patient should read.

    Groopman locates the source of uncertainty (to follow on from Martin Stockler’s comment above) with the disease and the human body’s response to treatment. This is not some abstract medical uncertainty, but the very real limits of knowledge of individual physicians and the body of medicine:

    “Each disease is uncertain in its outcome, and within that uncertainty, we find real hope, because a tumor has not always read the textbook, and a treatment can have an unexpectedly dramatic impact. This is the great paradox of true hope: Because nothing is absolutely determined, there is not only reason to fear but also reason to hope. And so we must find ways to bridle fear and give greater rein to hope.

    Good doctors acknowledge they are uncertain. Throughout the years, as a patient and a carer I have found, that how doctors manage uncertainty, their own and that of medicine in general, is most revealing of their skill as a clinician. A doctor who knows everything and always has a ready answer is not one I would be likely to visit again.

  2. Another important nail hit squarely on its head. Is uncertainty a characteristic of beings who think (thinkers), or of the information they are thinking about (things)?

    My view was identical to yours, that uncertainty is a characteristic of thinkers rather than things. That was until I argued the point with a friend struggling with their PhD project, and then started looking for evidence to support my view.

    I was surprised, and chastened, to find that the OED, and my other favourite sources, define uncertain as:
    1 Not able to be relied on; not known or definite. ‘an uncertain future’
    1.1 (of a person) not completely confident or sure of something. ‘I was uncertain how to proceed’

    Uncertainty, a state, is still defined first in terms of things, and only then in terms of thinkers.


    1 The state of being uncertain. ‘times of uncertainty and danger’
    1.1 usually uncertainties count noun Something that is uncertain or that causes one to feel uncertain.
    ‘financial uncertainties’


    Interestingly, certainty is defined first in terms of information, and then in terms of thinkers.

    I think the problem is using the word(s) uncertain(ty) in a way that obscures the source of uncertainty.

    If a doctor is uncertain, then it’s better for them to say ‘I don’t know’ or ‘I’m not sure’, than to say that ‘The situation/diagnosis/prognosis/etc is uncertain’.

    However, if the point is that the situation/diagnosis/prognosis/etc is inherently uncertain, as it often (always) is, then it’s better to be clear that it’s the information (thing) that is unclear, not what the doctor thinks about it.

    For example, a ‘positive’ result on a blood test for HIV does not mean that a person has HIV. The result may represent a ‘false positive’. In this situation, the uncertainty is an inherent characteristic of the piece of information and it’s implications, not of the thinker’s mind.

    Thank you for stimulating and provoking my thinking, yet again. As usual, the more I wrote, the less certain I have become. The topic warrants longer than I have allocated, and I hope to come back to it. Particularly to incorporate the concept of statistical uncertainty.

    My last thought is that this is yet another situation where people are using the same word to connote a range of different meanings. Ian Hacking’s study of ‘Probability’, and of many other things, is very instructive.

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