By Ron Epstein, MD
Several months ago, Paul Han, a physician colleague in Maine, asked if I’d review his book – then in preparation – about uncertainty. Uncertainty seemed like a timely topic for doctors and remarkably little has been written about it over the years. In his articles, Paul has taken uncertainty from a superficial discussion (“Do I know enough and where can I find the answer?”) to new depths. Paul talks about two kinds of uncertainty (1). The first is stochastic uncertainty. For someone who is critically ill, we might find statistics that indicate that 80% of patients with a similar presentation recover from XYZ, but no one can say whether they will be one of the lucky 80% or the unlucky 20%. While this kind of not-knowing can be anxiety-provoking, we have some idea of what is known and what is not. We have some sense of the terrain, some idea about the possibilities. We can calculate risks and then decide whether we want to take them.
The second kind of uncertainty is epistemic uncertainty. In these situations, we don’t even have a clear map of the territory. We feel lost; we don’t know what we need, nor whether what we need can be found. Among early maps drawn by explorers, there were fuzzy lines that faded into the background. Only later, maps contained areas that were labeled as terra incognita – unknown terrain – as distinguished from that which was known, or at least provisionally known. Here the challenge is not only statistical, but existential; we cannot even begin to calculate the risks and don’t know how we, as confused sentient beings, fit into the picture. And when the potential consequences are very dire (isolation, death, economic collapse), the associated anxiety has no anchor, desperately seeking a point of reference. It ceases to be a solvable problem; rather, it is a gut-wrenching nausea. Sense making backfires over and over again. The little wheel that spins on the computer screen when the circuits don’t connect. And when others, to whom we might anchor when feeling anxious, are equally unmoored, we are boats, perhaps floating, but adrift.
Dr. Ron Epstein with his grandchild, Summer
Sitting in my study now, I am just finishing reviewing Paul’s book, which arrived just 10 days ago. Who could possibly know that a book on uncertainty could arrive at a more uncertain time? In this moment, though, I look out on snow falling. It is quiet and beautiful. My home is comfortable. There are woods just beyond my backyard. I am with my wife, and feel loved and connected. We have spent the past week of evenings eating dinner in front of the wood stove, with more time together than we have had in years. My children and young grandchild, although far away, are well. Yet, we now have several friends and colleagues who have the virus. The peace and comfort of our home stands in contrast – unsettlingly – to the gut-wrenching nausea flavored with cognitive disruption and waves of anticipatory grief. However, knowing that the nausea is about the future, knowing that fear is an activity of the mind to predict and prepare (what the mind is so well-trained to do) – both of these can invite us to visit this place that we know as the present moment and to visit it perhaps a bit more often than usual, while also maintaining an awareness of our unknowingness of the future.
Each of us is looking for ways to stay safe, healthy and connected to self and others. As outrageous as it might sound, there are also opportunities to learn – about ourselves – and in so doing, prepare ourselves for whatever might come. What if, for a moment, we could just take a moment to be curious, not only about others, or the virus, but ourselves? What was that thought? Is it about the present or the future? Does it stick? Are there other thoughts? Is that thought shared, and with whom? When I feel connected, safe and robust, what happens to that thought? Does the thought have a flip side, another way of looking or experiencing? What if – no matter how frightening that thought might be – we could say that it’s a thought, a mental rehearsal, and decide whether to dwell there or not? What’s an appropriate way to respond?
If you’re interested in some brief practical tools to be more present in the face of uncertainty, Jud Brewer, the director of Brown University’s Center for Mindfulness, has made some short videos, each with a tool to address a different facet of experience. The latest is about making lemonade from lemons.
For me, music and poetry bring me closer to presence – and the present. In that spirit, here’s a poem by Lynn Ungar. Ungar evokes how we, as humans, are social beings, with hearts and touch that know no boundaries of space and time. She might say that social distancing is a misnomer – it is physical distancing with social connectedness.
We are all sad that we’ve had to cancel professional meetings and workshops, and many of us are wondering when we’ll once again be able to visit with aging parents, far away children and newborn grandchildren. But, in these times of unprecedented uncertainty, let’s make the commitment to touch and heal one another with our hearts, our presence, our energy, and our wisdom – and to act in a way that helps others to do the same.
1. Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making. 2011;31(6):828-838.
This essay was originally published in the Mindful Practice Newsletter for April 2020. Dr. Ron Epstein is the Co-Founder of Mindful Practice. The Gold Foundation offers Flourishing at Work: Mindful Practice for Clinicians and Leaders programs to our Gold Partners Council members to help support the well-being and resilience of clinicians and their compassionate care of patients.
