Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

“Now-right And Future-wrong”


Clear communication about uncertainty can help clinicians and patients better cope with unexpected or undesirable outcomes. 

In medicine the stories 

Come fast and thick 

In the hospital the unknowns twist 

And characters enter stage ER 

Faster than you can 

Dictate the  



When you are a certain kind of  

Black bones tired 

Everything feels like a dream anyway 

And so so emotional 

People die with disturbing regularity until it is only  

Disturbing the 

Families and they seem to be hamming up the  

Scene and you just want to 

Check the fridge to make sure you didn’t leave  

Anything smelly in it 48 hours ago 

When you left home 

But the fridge is near the bed so you 

Don’t although you hope you got all the 

Blood off  

Your shoes 


So that is when you start to see 

Now-right and future-wrong 

It’s about the time you stop….  

Needing to change the plot 

And stand back, a precise narrator 

Sometimes intervening, but always on script 

And you see that you are caught 

Because the now-right could easily be future-wrong 

And the people in front of you 

Can’t see it 


You can say all the [conveying uncertainty]  and [autonomous decision-making]  

You want but they will only remember 

It right if the ending is 


And you don’t write the endings 

The story is convoluted and you can 

Barely make breakfast, in fact you 

Didn’t eat that day 

Maybe longer 


Time can be a bitch 

When emotions happen out of  

The true  

Choice sequence 

And sometimes all you can do is 

Carve a space out of the air 

And a silence to emphasize 

That a decision is being made 

And everyone 

Including a trembling tremulous poorly fed and  

Sleep-starved you  

Will have to face 

The consequences 



Decision fatigue the AMA calls it, as if it could be so neatly summarized. What we wish patients knew about our work. It affects everything, our mental and emotional exhaustion, surgeons’ choice  to operate, whether to administer cancer screening tests. It leads us to overly rely on the status quo, the heuristic, the absolution of choice. Yet there is more: the unpredictable nature of the outcomes. What you know that they don’t: that you are not in control.  


We sometimes think we can control everything, but we can’t. And clinicians know the deep trauma that comes from pretending that we can—only to find out we were wrong. One only needs to reassure a patient falsely once, to remember the unending shame of claiming a right to a future we do not own.  


The body is a complex system. Chaos theory describes complex as “multiple component parts that interact in a nonlinear fashion, and the results of their interaction are often greater than the sum of their parts.” Perhaps the most difficult part of medical practice is when the outcomes affect how patients and their loved ones view you, even if you did everything right. 


We say terms like “conveying uncertainty” in training. But the reality is this is just compassion. When you know that a decision can only be right in the moment, and only sometimes in the past. When your patients don’t. When you express this the best you can. And when you forgive them for not understanding. 









This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.