Exploring the unknown.

At a recent family event a relative explained in long suffering terms how no-one knew why she had a persistent, low level tachycardia at times. The issue appears benign and this person had been thoroughly scanned, tested and observed over time. I bit my tongue. However, I wanted to say that what would have been more helpful for this person is if the GP, cardiologist and others said more clearly that they did know what was happening. There was no clearly identifiable pathology or disease and although we aren’t sure why some peoples’ hearts beat a little faster we can be reassured that in this case it is within the normal range, just at a more distant end of normal.

We live in a time of tyrants, of dictators who infiltrate democracy. It seems when I listen to these abhorrent individuals that what is most appealing to their followers is a sense of certainty. I don’t propose that there is much to learn from such rhetoric, but there may be a message that comes from understanding why many people will vote for a known dictator despite this not being an objectively good thing. There is a power in answers that the search for a perfect answer can leave behind. An imperfect answer may be a more therapeutic thing to many patients than a perfectly correct but unsatisfactory or misunderstood answer.

Within medicine I have long campaigned and written about managing uncertainty, that being comfortable with the known unknowns and the unknown unknowns is a key part of being a clinician. However, the story above of my sad relative who feels like they are a medical mystery; highlights how we sometimes compound misery by trying to too accurately reflect the complexity of medicine in a fashion that can be unhelpful for patients.

I don’t advocate here for half truths or benign confabulation. Simply said I wonder if when explaining something that is not pathological, or is pathological but we can not influence it, that instead of saying we don’t why it has happened we could instead provide a landscape. Upon this landscape we can draw the neighbourhoods, the topography, on which to settle the city of our uncertainty. It may be true that the uncertain city’s streets are not mappable but we can still provide a name, a location. The journey taken to a point of uncertainty is usually a very clear one in medical terms, whether the decision has been made to investigate a thing or not is a decision made on the foundations of decades of knowledge, experience and scientific method.

The relative in my story above would likely not have welcomed my input, I have a different role in their world and the consequences of changing roles can create fissures in the delicate landscape of family relationships. Moreover, I would always be lacking parts of the picture as an informed observer, the desire to do well would nonetheless be ineffectually mirrored in the reality of consequence.

It is therefore as a medical practitioner that I hope my actions in exploring the meaning of uncertainty may make a difference. Sometimes we have to cross the bridge of knowledge before we can confidently say we don’t know and when we take our patient blindfolded and reveal their destination we shouldn’t be surprised if they seem upset.

(The family member referenced in this article has reviewed the article and given consent for the details contained within to be shared in this format.)

Originally published in the BMJ SPC blog on the 2nd March 2025.