Learn to Navigate the Seas of Uncertainty in Rheumatology Training

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Rheumatology is a field rife with uncertainty. With regard to both diagnosis and treatment, we live in a world of rare diseases that are difficult to study. As a result, we are often left without an answer to our diagnostic dilemmas and without clarity when deciding the best treatment options for our patients. For rheumatologists to cope with, and thrive during, times of uncertainty requires that we recognize and prepare for this unique challenge of our field.

Navigating the seas of incertitude can be a formidable task for a fellow. I remember the astounding feeling my first month on the inpatient consult service as I experienced the steep learning curve of understanding complex rheumatic diseases. At the start of training, we don’t yet have the illness scripts needed to make accurate diagnoses. Creating accurate illness scripts requires pattern recognition, yet our diseases don’t always follow the rules or fit into neat boxes. Learning to understand such enigmatic disease processes can, at times, feel like an immense task.

Dealing with uncertainty as a fellow can also be emotionally burdensome. During internal medicine training, a sense of satisfaction comes from the concrete inputs and outputs in our decision making when caring for patients with such conditions as congestive heart failure and sepsis. In contrast, a new rheuma­tologist can sometimes feel like ambiguity is the norm.

As internists, we strive to find definitive answers, and immersion in a field that does not always offer them results in an uneasiness not previously experienced in our medical training. But this also offers a unique challenge and is part of the fun and draw of rheumatology as a field. Many internists who choose rheuma­tology are captivated by the detective work involved.¹ Yet there is a crucial, humbling lesson to be learned in not always solving the mystery. Understanding this is an important step for a rheuma­tology fellow.

Although it is frustrating not to know the answers ourselves, it is even more difficult at times to not have answers for our patients. These are challenging conversations to navigate. We learn the art of both simultaneously exuding confidence while also endorsing flexibility. We learn how to recommend medications without certainty of their benefit for that particular patient.

We approach these quandaries by practicing shared decision making and by explaining all the risks and benefits of our recommendations. But the realities of uncertainty are part of our relationships with patients. Embracing this aspect of our physician-patient relationships presents yet another monumental endeavor for trainees.

Heuristics

We must understand how our minds function during times of uncertainty. In their now-famous analysis, Amos Tversky and Daniel Kahneman outlined the ways biases and heuristics affect our judgment during times of uncertainty.² Heuristics, originating from the Greek word for discover, are methods or rules used to aid problem solving in the face of complex problems or incomplete information. We all use heuristics, often without realizing it, when making decisions. Tversky and Kahneman described how, when trying to assess uncertain probabilities (such as the likelihood a patient has lupus), we often use heuristics that, while at times can be valuable, can also lead to systematic errors.

Recognition of such biases in medical decision making has become more commonplace, with such terms as representativeness, availability and anchoring heuristics now more prevalent than ever in our lexicon. Understanding the ways heuristics can lead to cognitive errors is even more crucial for rheumatologists given the greater extent to which we operate under conditions of uncertainty.

One gets the feeling the tendency to make medical decisions under the effect of heuristics is ubiquitous in rheumatology practice—and with good reason; it is a natural part of the way our minds process data. We may be led to a rare diagnosis by recalling a familiar case we recently saw, falling prey to the availability heuristic. One can imagine how this may aid us in making a good medical decision, but also how it may lead us to the error of missing a much more common condition. How often do we suspect a treatment may work based on a previous experience in which it was successful, although data may suggest the treatment is not as effective as our bias suggests? We may overlook an alternative option due to the representativeness heuristic.

Acknowledging the impact biases have on us is important at all levels of practice, and early in one’s rheumatology career may be the best time to start.

Coping Tips

During an interview for fellowship I was asked how I would deal with not knowing the answers. My green answer was that good communication with patients and shared decision making would be my coping mechanisms. This strategy has been important, but I have come to learn that unraveling uncertainty is a more complex task, full of the emotional and cognitive pitfalls outlined above. It might prove fruitful to incorporate mechanisms for dealing with uncertainty and our cognitive biases into training.

Reflection is one way to tackle the emotional aspect. A rheumatology case conference can quickly turn into a heated debate due to all the differing opinions, but we rarely have time to reflect at the end on how we feel about not knowing the answer and about how we bridge this gap with our patients. Structured time for reflection may help trainees process these dilemmas with more ease.

Modeling by mentors is another method by which we learn how to have challenging, uncertainty-laden conversations with patients, but feedback and discussion about these interactions could further instill in trainees the skills to thrive in such situations.

In addition, training in cognitive biases could also be useful. Reilly et al. described a curriculum-based inter­vention that im­proved internal medicine residents’ knowledge and recognition of cognitive biases.³

During fellowship, we are informally taught good habits to avoid some of the common pitfalls in medical decision making, but building this type of education into formal curriculum could prepare trainees to more readily recognize heuristics during their careers as rheumatologists.

In Sum

Sir William Osler once said, “Medicine is a science of uncertainty and an art of probability.” Although we have made tremendous strides over the past several decades in our understanding of rheumatic disease, unknowns will remain pervasive in our field. Becoming a proficient rheumatologist requires we recognize our own human fallibility in our decision-making process and learn to cope with the restlessness that comes when definitiveness is obscured from our view.  

Richard Zamore, MD, MPH, is a rheuma­tologist at Lahey Hospital and Medical Center, and was formerly a rheuma­tology fellow at the Hospital of the University of Pennsylvania, Philadelphia.

References

1. Kolasinski SL, Bass AR, Kane-Wanger GF, et al. Subspecialty choice: Why did you become a rheumatologist? Arthritis Rheum. 2007 Dec 15;57(8):1546–1551.
2. Tversky A, Kahneman D. Judgment under uncertainty: Heuristics and biases. Science. 1974 Sep 27;185(4157):1124–1131.
3. Reilly JB, Ogdie AR, von Feldt JM, Myers JS. Teaching about how doctors think: A longitudinal curriculum in cognitive bias and diagnostic error for residents. BMJ Qual Saf. 2013 Dec;22(12):1044–1050.