Picture this.

You walk into your doctor's office for an urgent visit for new distressing symptoms. He (or she) takes your blood pressure, temperature, heart rate. All within normal limits. He asks you several questions pertaining to your symptoms, does a thorough exam and perhaps orders a quick in-office lab or two. You ask him what he thinks is going on.

The Quandary

If it's a slam-dunk diagnosis, the branch point in this doctor-patient scenario is relatively straightforward to navigate. Your doctor will let you know what he thinks and will offer his advice (reassurance, further testing, medication, etc). Ideally, a shared decision is made to pursue a certain treatment plan and appropriate follow-up is provided.

Unfortunately, it is rare for physicians to make diagnoses on the spot. More often, investigating distressing symptoms requires thorough clinical reasoning that involves the consideration of a range of probable diagnoses based on the individual patient's risk. Labs, imaging and diagnostic procedures may help rule in or rule out possible underlying etiologies for symptoms, but not all tests are perfect and may cause more harm then good (e.g. false positives or false negatives). Often times serial office visits are required to clinch the diagnosis, and frequently these symptoms will resolve before a diagnosis is made.

Given that many diagnoses are not made on the first office visit, I've offered the above hypothetical scenario to many non-medical friends and asked them how they would want their physicians to communicate uncertainty at the end of such a visit.

The Opinions

The most common responses that I received were what I thought as a clinician to be most reasonable: Physicians should attempt to reassure their patients that these symptoms aren't immediately life-threatening, explain that more visits and perhaps more tests are needed and offer scenarios in which patients should return for a more urgent appointment. I clearly have smart friends.

What interested me the most was that very few replies to this scenario included a desire for physicians to directly communicate their uncertainty. In fact, most friends and family would rather their physician not say phrases such as, "I don't know what's causing these symptoms yet," or "I'm unsure of what's going on at this point."

On the one hand, I understand how this can be unsettling. I couldn't imagine patients being super excited to hear that their doctors are uncertain of what's going on, especially if these symptoms are particularly distressing. However, shouldn't patients have the right to know of their doctor's uncertainty? Or should doctors protect their patients from further anxiety and perhaps their own professional image by withholding such statements?

My View

In order to maintain the trust of patients and encourage honest and open communication, I think it's important for physicians to state uncertainty when an explanation of symptoms is unclear or prognosis of disease is unknown.

Although often difficult for both physicians and patients alike, I believe that withholding this information can breed unreasonable expectations, propagate medical paternalism and perpetuate further miscommunication between doctors and patients.

Therefore, I make it a point to include a statement of uncertainty when offering my assessment and plan to patients in situations where a constellation of symptoms don't immediately add up by the end of an office visit.

Am I right to do this? Well, I don't know.

But I do know that either way, I'm going to be honest about it.

Originally written for The American Resident Project

3 Responses to When Doctors Don’t Know

Brian Secemsky, M.D.

Medical writing for patients, students
and practitioners.

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