James Belarde
“Medicine is a science of uncertainty and an art of probability.” -William Osler
The Big Sick, a 2017 romantic comedy written by husband-and-wife team Kumail Nanjiani and Emily Gordon, tells the true story of a mysterious illness that strikes Emily early in their relationship. The doctors initially overwhelm her family with medical information, leaving them feeling powerless at the mercy of seemingly omniscient caretakers. Later in the film though, Emily’s mom Beth relates to the physicians with an epiphany that humanizes them. On the eve of a planned surgery for Emily, Beth announces to Kumail, “I feel good about the surgery.” He agrees, adding, “These doctors know what they’re doing.” To which Beth replies, “No they don’t. They’re just winging it like everybody else.”1
Like most things in life, even the best medical care is shrouded in uncertainty and chance. Doctors constantly adjust their approach while seeking the best treatment for patients. To examine this, I spoke with Dr. David Chong, an attending physician in the Intensive Care Unit with 25 years of experience and the Program Director of the Internal Medicine Residency at Columbia. After sharing a few great dinosaur jokes his son tells (“Why can’t you hear pterodactyls using the bathroom? Because their ‘p’ is silent.”), Dr. Chong stressed how important it is for doctors to accept working with uncertainty.
“In medicine, you have to be comfortable making decisions when you don’t have all the information.” He continues to explain that healthcare teams guess about 98% of the time, and while it’s an educated guess backed by evidence, it’s still a guess. This realization can unnerve medical students and residents early in their training. After all, until entering the clinic, aspiring physicians dedicate their academic lives to knowing the right answer. They watch hours of lectures and study hundreds of pages of material so that, come test day, they know with exact accuracy which answers to circle.
Unfortunately, patients don’t usually come to the hospital dressed in multiple choice scantron exam sheets (or fortunately if you consider what this would do to the fashion world). So how do younger doctors transition from the relative certainty of textbook medicine to the directed guesswork of a clinical setting?
Dr. Chong sees it as a gradual progression that comes with repetition and experience. “When you’re an intern, you mostly just do what you’re told.” But as these novice physicians spend time treating patients, they start to feel comfortable making small decisions. Eventually they build their knowledge base and begin making big choices, running large teams in higher stakes situations. Dr. Chong notes this is most evident in the second-year residents, who are responsible for running emergency teams when a cardiac arrest occurs. There is a marked change in these residents between when they first start managing these highly chaotic scenarios and the end of the second year after they’ve had significant experience with them. It’s all in the repetition.
Of course, with big choices come opportunities for big mistakes (a sentence in no way modeled after a famous Spider-Man quote…). Dr. Chong believes these can be great sources of education. “Part of medicine is really embracing your errors and learning from them.”. But he also notes that doctors like to be right. “If someone tells you you’re wrong, it’s almost an affront to your character.” Thus, the challenge is getting inexperienced doctors to suppress that ego and realize mistakes are a benefit to their learning, especially when these errors rarely result in permanent harm. One way Dr. Chong does this when orienting new residents is by stressing the point with inspirational sports commercials about using defeat to drive success. New doctors thus receive early encouragement that mistakes can be okay. This in turn grants greater confidence to approach uncertain situations with active decisions because the choice will either be right or a mistake that will improve their abilities in the future.
There is another discipline where a constant repetition of big choices in the face of uncertainty and dealing with unavoidable mistakes is an important training tool: improv comedy. Amey Goerlich is a Los Angeles-based veteran improvisor and improv teacher with over 16 years of experience. In addition to co-creating Humans Being, an improv card game, she brings her vast (and hilarious) improv experience outside the world of comedy performance by teaching numerous corporate improv workshops, including classes for physicians. Speaking with her, she highlights that, in workshops, “doctors often like to be correct and get it right,” mirroring observations Dr. Chong shared.
However, rather than fight this tendency, Amey uses it to encourage them to make big choices. For example, she assigns a task to accomplish at some point in an improv scene (i.e. being attacked by a swarm of bees). It’s then on the doctor to make sure this is done sometime before the scene ends. It doesn’t matter how they do it, but in having the task, they feel a sense of being correct when they manage to work it in. The more they do this, the easier it gets for the doctors to make decisions despite the uncertainty of the scene.
Amey also uses exercises in these workshops to stress learning from one’s mistakes. In one, students pass a counting pattern around a circle using hand motions. If someone messes up, the pattern starts over. The one who made the mistake runs two laps around the circle, paying close attention to the counting while she does. Then, when she inserts herself back into the circle, she can pick up the count and keep helping. This routine allows students to recognize error, stay focused on the team while acknowledging their mistake, and rejoin the group better prepared after learning from it.
Regardless of whether these skills are strengthened through repetition in the hospital, improv exercises, or both, doctors become equipped to handle the ambiguity and missteps inherent in medical work. By embracing this, they also gain a clearer picture of the role of the physician and its limitations. In our discussion, Dr. Chong mentioned that doctors occasionally “have an inflated understanding of how godlike we are.” But as Beth in The Big Sick appreciates, doctors aren’t deities working on a higher plane to enact cures. They are as human as the patients, working alongside them as a team, with similar shortcomings and uncertainty. Dr. Chong summarized this nicely. “We’re part of this system. We’re part of people getting sick and getting better. But we’re not gods.”
References
- The Big Sick. Directed by Michael Showalter, Amazon Studios, 2017.
