Oncologist Reflects on Admitting Uncertainty in Patient Care Over 25 Years

Ranjana Srivastava, an oncologist, shares her experiences in medicine, emphasizing the value of admitting uncertainty to patients. In her view, medicine offers opportunities for individuals with diverse interests, from research to clinical practice.

However, some doctors become disillusioned and leave the field due to familiar challenges. Medical knowledge has advanced significantly. HIV wards, once filled with severely ill patients during Srivastava's training, have closed in most wealthy countries due to effective treatments.

In one case, doctors retrieved a clot from a young neighbor's artery after a stroke, preserving his life and function. An acquaintance donated a kidney to a sibling, allowing both to continue their lives with minimal disruption. In oncology, successful therapies were limited in the past, and palliative care was underdeveloped.

Societal expectations for patient involvement in care were emerging, with doctors holding substantial authority in hospitals and patient decisions. The field has since changed considerably.

During her first year as a qualified oncologist, Srivastava managed facts, prescribed chemotherapy using handbook guidelines, interpreted results, and cared for sick patients. However, she struggled with patients' deeper questions. For instance, a recently separated father asked about his position on survival curves to plan time with his children.

A matriarch inquired if a median survival of 12 months meant she would definitely live to see her grandchild due in six months. A single parent considered a drug with less than 5% response rate but near-universal risk of severe harm. Srivastava often thought, "I don’t know," in response to such queries.

She also faced dilemmas in explaining mixed tumor responses—some shrinking, others growing—and in conveying that others' chemotherapy experiences do not predict individual outcomes. Early in her career, she envied colleagues' self-assurance while recognizing the significant impact of oncologists' words, such as informing patients they may not live to see a child's graduation or suggesting a wedding occur immediately.

Educated guesses rely on data, but uncertainty remains, requiring courage and tact to discuss with patients. Building trust involves projecting confidence, yet mumbling "I don’t know" repeatedly could undermine it. Srivastava notes that being certain without accuracy poses greater issues, as patients with aggressive diseases sometimes exceed predictions, while those with good prognoses relapse.

After 25 Years After 25 years, Srivastava says "I don’t know" more frequently, as increased exposure reduces total certainty. Contrary to fears of eroding trust, patients appreciate this vulnerability rather than questioning the doctor's competence.

The article underscores that admitting uncertainty does not equate to offering nothing, allowing for honest discussions in patient care. This reflection occurs amid ongoing advancements in oncology, where survival rates improve but individual outcomes vary.

Affected parties include patients facing serious illnesses, their families planning life events, and medical professionals navigating ethical communication. Future implications involve continued training for doctors to balance confidence with transparency, potentially enhancing patient satisfaction and shared decision-making.