Communication Skills:
Addressing Uncertainty


Addressing uncertainty is central to prognosis. Patients do not think of themselves as “statistics,” and may view themselves as the exception, rather than the rule. The evolutionary biologist Stephen J. Gould famously captured this perspective in his wonderful essay, “The Median Isn’t the Message,” after being diagnosed with mesothelioma. Talking with patients about uncertainty involves several key steps. There are varying levels of uncertainty over most diagnostic and treatment decisions, such as whether a fever is a result of a urinary tract infection or whether someone will benefit from a statin for primary prevention. Just as the uncertainty does not absolve the clinician from making decisions in these cases, prognostic uncertainty does not absolve the clinician from thoughtfully discussing prognosis with patients.


Notice how the clinician in this example does the following steps in addressing uncertainty:

  1. State the uncertainty associated with the prognosis. This usually means giving a range, “Your life expectancy is five to seven years. It could be more, it could be less, but if I had to give a best guess, that is what I would say.”
  2. Normalize the uncertainty. Notice how Dr. Schonberg says, “Please don’t take what I say about prognosis as a prescription. It’s an estimated guess.”
  3. Respond to the emotion generated not just by the prognosis, but by the inherent uncertainty associated with prognosis. Sometimes people get caught up in the uncertainty, hoping and waiting for a future that may never arrive. This step involves responding to the emotion and refocusing from the future to the present.

Take a minute to think about what worked well in this example and what can be done differently.

  1. Gould SJ. The Median Isn’t the Message.
  2. Smith AK, White DB, Arnold RM. Uncertainty – the Other Side of Prognosis. N Engl J Med. 2013 Jun 27;368(26):2448-50.

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