IDEAS AND OPINIONS Annals of Internal Medicine

If You Can't Beat It, Join It: Uncertainty and Trust in Medicine
Katrina Armstrong, MD, MSCE

T he quest to eliminate uncertainty in clinical decision

making has become central to biomedical research
over the past 50 years, driving the emergence of evidence-
building trust remains critically important. Although ev-
idence suggests that recognizing intrinsic uncertainty
may help rather than harm this effort, many physicians
based medicine, precision medicine, and most recently, are uncomfortable sharing uncertainty with their patients.
biomedical artificial intelligence. This quest is unsurpris- We worry that admitting our limited ability to predict the
ing given that uncertainty discomforts most humans, who likelihood of different outcomes, the implications of a
have cognitive and emotional drives to eliminate it from test result, or the optimal therapy for a specific patient
their decisions. When physicians are uncertain about how will lead to a loss of patient confidence. Although un-
a condition will progress or respond to treatment, they certainty is uncomfortable, at least 1 study suggests
can feel like they let patients down and fail to have the that appropriate expressions of uncertainty can lead to
predictive ability they desire. Paradoxically, however, the stronger physician–patient relationships. In that study,
very uncertainty that creates this discomfort can have an primary care encounters where the physician used di-
important positive effect on medical care, particularly the rect expressions of uncertainty, such as “I don't know”
trust between patients and their physicians, hospitals, and or “It's not clear,” had higher levels of positive talk, pa-
health care systems. tient engagement, and patient satisfaction (6).
Trust is the belief that another person or entity will Hiding uncertainty can also have a large downside.
act in your interest in the future (1). Both interpersonal Patients frequently access many sources of information
trust (that is, between a patient and physician) and in- about their medical care, particularly for high-stakes
stitutional trust (that is, between a patient and hospital decisions. If a second opinion or an Internet site sug-
or health care system) are critical for the functioning of gests that a physician has withheld information about a
health care, including patient engagement with provid- decision, the patient may question the physician's com-
ers and adherence to recommendations. Building trust petency or honesty, including whether financial motives
is particularly important for groups with a history of outweighed the patient's interest. Trust is fragile, and
negative experiences with health care, such as racial or concerns about competency, honesty, and motives are
ethnic minorities. We know intuitively that trust is only key steps toward loss of interpersonal trust (7). Such
necessary when an important adverse outcome is pos- events can also threaten institutional trust in the health
sible. For example, trust is often invoked for decisions care system. The fallout from the changing recommen-
in health care and government but is largely irrelevant for dations about mammography screening for women
choosing lunch or clothes. Perhaps less intuitively, trust in their 40s illustrates how betrayed patients feel by
also requires uncertainty about the likelihood of these health care institutions when the decision turns out not
high-stakes outcomes (2). Belief that someone will act in to be so certain (8).
your interest becomes necessary only if the future is un- Thus, the question is not whether to share uncertainty
certain and may be influenced by those actions. with our patients, but how best to share it to create trust
This dependence of trust on uncertainty has been instead of unnecessary anxiety. Although research indi-
demonstrated in experimental studies. One study of hy- cates that communicating uncertainty is challenging,
pothetical purchasing decisions varied the amount of some principles can be helpful. Such communication is
information given to the buyer, creating a scenario with most effective when embedded within an empathetic,
considerable uncertainty about the quality of the good positive, and partnering relationship (9). Theoretically,
and a scenario with no uncertainty. As hypothesized, it becomes easier and more effective over time as the
after multiple purchases, the buyer reported higher lev- physician–patient relationship strengthens. Evidence
els of trust in the seller in the high-uncertainty scenario about the prevalence of low numeracy and cognitive
than in the low-uncertainty scenario (3). Similarly, other biases argues against using potentially misleading lev-
experiments have compared exchanges based on ne- els of precision, even when such numbers are available
gotiated contracts that minimize uncertainty about fu- (10). For example, the likelihood of a response to ther-
ture actions with those based on reciprocal relation- apy can be expressed as a numerical range with a qual-
ships that have inherent uncertainty. Trust was again itative estimate rather than a single number. Similarly,
higher in the setting with more uncertainty (4). life expectancy can be explained as having weeks not
What does this mean for medicine? Advances in months or months not years left. For most diagnostic
biomedical research will continue to improve the accu- tests, we should emphasize that the test result shifts the
racy of information available for clinical decision mak- probability of a particular diagnosis up or down rather
ing, but uncertainty in clinical medicine is unlikely to than providing a definitive answer. Finally, the greatest
disappear any time soon. In fact, by describing the comfort to a patient can be hearing that, regardless of
breadth of human variation, these advances have high- clinical uncertainty, their physician will be with them no
lighted the enormity of such a task (5). Given this reality, matter what the future brings.

This article was published at Annals.org on 17 April 2018.

818 © 2018 American College of Physicians

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If You Can't Beat It, Join It: Uncertainty and Trust in Medicine IDEAS AND OPINIONS
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K. Development of a revised health care system distrust scale.
Department of Medicine, Massachusetts General Hospital,
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Grey/Bigelow 7th Floor, 55 Fruit Street, Boston, MA 02114;
/s11606-008-0575-3
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Author Contributions: Conception and design: K. Armstrong.
Drafting of the article: K. Armstrong.
Critical revision of the article for important intellectual con-
tent: K. Armstrong.
Final approval of the article: K. Armstrong.
Administrative, technical, or logistic support: K. Armstrong.

Annals.org Annals of Internal Medicine • Vol. 168 No. 11 • 5 June 2018

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