Heroes Not Zombies

Doctors are expected to be sure. I can’t remember the actual reference but years ago I read a study conducted by a UK General Practitioner where he randomly allocated his patients with acute viral infections (I think) into two groups. One group he told he knew exactly what was wrong with them, it wasn’t serious, there wasn’t a treatment for it but it would soon be better. The other group he told he thought he knew what was wrong with them but couldn’t say for certain, didn’t think it was serious but expected it would soon go away by itself and there wasn’t a treatment. In both cases he was telling the truth. The emphasis was on greater or lesser certainty. He found that when he used the “I’m sure” style of consulting, the patient’s satisfaction and the outcomes were better. He called this the “good consultation”. That study always bothered me because it seemed to me that the best consultation was the one which didn’t pose the doctor as the all-knowing expert. And yet….I also knew that the doctor who didn’t seem to be sure of anything didn’t do his or her patients many favours either.

Jerome Groopman, in How Doctors Think, says

What we know is based on only a modest level of understanding. If you carry that truth around with you, you are instantaneously ready to challenge what you think you know the minute you see anything that suggests it might not be right.

I agree with that. We often forget that what we know is always only a little. My first consultation with a patient lasts one hour. It is very common for people to say at the end of that hour that they feel they’ve been listened to properly for the first time. I hope they feel understood, but I always say in my summing up with them, that to spend an hour with someone might seem a long time in medicine but who can know a person in an hour? Yes, I hope I understand this person better and I hope they have gained some understanding of themselves too, but I can surely know only a very little about their life in one hour. Goodness, it takes us a lifetime to understand ourselves let alone another person! I find it helpful to keep that in mind, to never assume I know all that I need to know about a patient. There will always be more to discover, and always be a better understanding to be reached. I also agree with that second sentence about noticing things that don’t fit and being challenged by that. Certainty is really the enemy of understanding in that regard. People judge others, or claim to know “for sure” all that needs to be known about a person or a subject, and that stops them from thinking.

I find that latter issue common amongst people who dismiss homeopathy because it doesn’t fit with their current understanding of how the world works. Actually it amazes me that many such people claim to be “skeptics” because the original skeptics never did claim certainty!

Jerome Groopman describes three kinds of uncertainty – that which comes from not being in command of what is known; one from the limitations of what is known by humankind; and the third is the inability to distinguish between these two limits – in other words when we are not sure it our lack of certainty is due to our personal knowledge or to what is known by humanity. That’s quite an interesting take on this issue. We can never have perfect personal knowledge and often we’ll doubt because we think if only we learned a bit more we’d know for sure, when actually everybody shares our imperfect knowledge.

I do think that certainty is the greatest enemy of an open mind. I often come across writing on the web, or in books, where the person’s mind is shut tight – all because they think what they know is the absolute Truth, and nobody can tell them anything. However, we do need a degree of certainty to be able to function on a day to day basis. Groopman again –

the denial of uncertainty, the proclivity to substitute certainty for uncertainty, is one of the most remarkable human psychological traits. It is both adaptive and maladaptive, and therefore both guides and misguides.

and

there are limits to living with uncertainty. It can paralyse action.

So what to do? Be more sure? Or try to live with a greater sense of uncertainty? Carmine Coyote recently wrote about this in Slow Leadership. I liked her conclusion –

The options you have today should be seen as “templates” that you can start to modify and shape into something better; not some immutable position that must be accepted unaltered. Those who favor a position always like to characterize their own as the only possible one, and frighten you with the supposed dangers of the opposite choice. Their opponent do the same thing. Neither group want you to consider a middle path, since that weakens their claim that you must choose only between them. In reality, there are always going to be other options, many that haven’t yet been discovered or created. Some of these may be much better that those available today. If we aspire to be leaders of any kind — or even just to live a full and happy life — it’s our job to try to find them. Choosing only between what’s currently available appeals to the macho mind because it’s quick, simple, and appears decisive. Finding new options requires time, thought, and the willingness to sit with uncertainty for maybe long periods — all things that are anathema to today’s short-term,Hamburger Management leaders. It’s that attitude that helped to get us into the mess we’re in.

Excellent. So, that’s what to do, isn’t it? It’s decisiveness based on careful attempts to make your best understanding, whilst keeping you mind open to alternatives and new information. Essentially its about living consciously with the knowledge of uncertainty and making the best choices you can make each day in the light of your present understanding.

As is so often the case, there’s no black and white, right or wrong answer to this. We are dynamic, constantly grow