COMMENT

http://dx.doi.org/10.5546/aap.2018.eng.92

Managing uncertainty in medicine

Uncertainty is the feeling of anguish (fear) experienced when perceiving the lack of control one has over a certain situation, the course of which is consequently deemed as unpredictable. However, certainty is always an illusion, given that all the variables that determine the course of a situation are never controlled, either due to ignorance of its causes, or because of the lack of the means necessary to accomplish it. Hence, certainty is always subjective, the feeling of control that accompanies it being the result of the limited knowledge that we have about its causes (ignorance) and/or the overestimation of the means available to resolve it (hubris).

From all the foregoing, it follows that uncertainty is, to some degree, ultimately the result of lack of self-esteem, a situation to which a person is exposed when they are I-have subjects rather than I-am subjects-in other words, when they consider themselves competent because of what they have instead of because of what they are. Accordingly, when they "lose control" over a situation, uneasiness prevails at once.

On the contrary, the antidote against uncertainty consists in becoming an I-am subject, where self-esteem, a condition different from pedantry (in which a person is an I-seem subject and not an I-am subject), is based not on the feeling of having control over a situation (egocentric position), but on the fact that one is a trained professional (I-am), who is committed to the situation, and willing to deploy all available resources (material, intellectual and emotional), both internally and externally (individual and team work), in order to achieve an optimal management of an issue (holocentric position).

The extrapolation of these concepts to the medical care setting is fundamental, because it highlights the importance of avoiding making the error of seeking certainty from having, for instance through the unnecessary accumulation (I-have) of ancillary studies (overprovision of healthcare services) and prescription drugs (polypharmacy), instead of accepting the presence of uncertainty without suffering the anguish inherent to it, which is accomplished by being an I-am subject, for which the following strategies can be adopted:

• Creating a network of therapeutic containment, where one is part of a cohesive entity, the team, and where all those who can contribute to the success of a treatment (patient, family members, nurses, colleagues, etc.) are part of the team, a network developed based on the daily exercise of respect, empathy and good rapport. The idea is not to be the core of a pyramidal structure (egocentricity) but the engine of a multinodal reticulated structure (holocentrism), along which treatment flows and the anguish of uncertainty becomes diluted, so that the network acts like an armor protecting each and every team member.

• Accompanying the sick-let us bear in mind that to be with someone is a way of being an I-am subject, of being present at a given time and place. Being present allows the ongoing evaluation of the patient's condition and of the state of resources for his or her treatment, thereby favoring the swift and timely readjustment of the course of action depending on what is really happening and not on what we assume is happening. Being present increases the knowledge of facts and the ability to react, and it also contributes to dulling the anguish of uncertainty.

It is not a matter of seeking control over the diagnostic-therapeutic process (attachment) but of being part of it (detachment), feeling as one of the variables at play in favor of the patient, which generates the confidence that neutralizes the anguish of uncertainty, confidence that translates into active and rational faith; that is, faith born not out of magical thinking, but of being aware of what is being done and of the reasons that support these actions. Ultimately, trust stems from feeling like one of the determining variables of the process, of being able to be one with the process (love) and to be able to flow with it (freedom). In this way, the anguish of uncertainty is transformed into the certainty that we are knowledge that results in action and commitment through the workings of love.

Carlos G. Musso, M.D.

School of Medicine, Instituto Universitario del Hospital Italiano de Buenos Aires - Argentina

REFERENCES

1. Musso CG, Enz PA. El arte como instrumento para aprender a sobrellevar la incertidumbre. Arch Argent Pediatr. 2015;113(6):485.         [ Links ]

2. Fromm E. ¿Tener o Ser? Ciudad de México: Fondo de Cultura Económica; 1976.         [ Links ]