Lessons from philosophy on facing uncertainty  

By James Aluri, MD, MA, Johns Hopkins Medicine 

It was my last rotation of intern year. I was ready to emerge from the suffocating schedule and inhale the freeing air of PGY-2. One morning, a team member presented a new admission that I was assigned—a middle-aged man with cocaine in his urine toxicology screen. The senior resident concluded this would be a quick discharge after a day at most and wondered why the patient hadn’t been discharged from the ED already. I remember the confident certainty in that assessment. I also distinctly remember pouring over the ED notes and thinking that two things argued against a quick discharge. For one, the patient’s mental status fluctuated from confusion to clarity and back to confusion at least once in the ED, which was not the typical clearing pattern from intoxication. Secondly, our colleagues in the ED, who see intoxicated patients all the time and don’t admit many who simply need to wait for a substance to metabolize, felt this patient merited admission. Intrigued, I trudged with our team over to the ED. Just as we arrived, one of the RNs was moving our patient out of the room and informed us: “He just had a seizure, we’re sending him to neuro instead.” 

Philosophy and certainty 

For centuries, thinkers that we now call “philosophers” sought certainty. Philosophers spent years making arguments trying to convince others (and themselves) of their conclusions. From Descartes’ cogito, ergo sum to Hume’s problematizing of the is-ought divide to Kant’s categorical imperative—many people felt certain of those conclusions for decades. But over time, we’ve realized the realities addressed by those claims are more complex than they first seemed. 

Medicine is messy 

In pre-clinical medical courses (and in TV series like “House”), medicine offers a mirage of the certainty in cogito, ergo sum. With enough intelligence, the right questions, and the right observations, you can confidently deduce the diagnosis. Once I started clerkships, I realized that clinical practice—from diagnosis to treatment selection to patient-clinician dynamics to healthcare financing—is fraught with the uncertainty that stems from complexity. No more multiple-choice questions describing patients with 90-words of symptoms, a single disease process, and one right answer. 

Reflections from studying philosophy 

In my graduate school philosophy courses, I read works from dozens of brilliant thinkers. Many of them disagreed with each other. I soon realized that it would be hard to determine which smart sounding argument was right with any certainty. As a psychiatrist, I recognize I might face more uncertainty in diagnosis and treatment than other clinicians. Psychiatric diseases don’t reveal themselves in labs or imaging (but can still be reliably diagnosed most of the time). Still, I learned in my medical school training and internship in various parts of the hospital that uncertainty and complexity permeate medical practice. When I face uncertainty in medicine, here are some lessons I try to remember from my study of philosophy: 

1. Despite feeling certain that I know what’s going on, I should remain open to assessments from other clinicians—even if they don’t have the specialty experience that I have. 

2. Medical knowledge is incredible, but it’s not complete. I should remain perceptive to learning from the lived experience of the patient and their family, especially when the clinical picture is murky. 

3. When I’m not certain about what’s going on, I need more data and to seek advice from respected colleagues. 

4. It’s ok to tell a patient when I’m uncertain and explain what I need to do to learn more. 

5. When science (or philosophy)can’t give me a solution, being present and caring is still meaningful. 

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