** For the purposes of anonymity and confidentiality this interview has been fictionalised – no one real-life doctor corresponds to one character in the following piece. Rather, it is an amalgamation of views and statements from a number of healthcare professionals along with my own perceptions and ideas**
Typically, hospitals are places we associate with science, biotechnology and precision. This biotechnology - be it the proven technologies or the latest treatment or the endless push for more - goes on to create hope. Hope can be seen in many different corners of a hospital - from hoping the scan is clear, to hoping the treatment works, to hoping there is a new clinical trial, to hoping this round of chemo works. Deeply intertwined with the sentiment of hope, is uncertainty. We can hope, but we can never be sure. While doctors do their best to reassure and assuage their patients’ anxieties, they can never provide unequivocal certainty.
In many ways, uncertainty - something that is considered antithetical to the precision of science and all the 'ologies' therein - is written into medical protocol. Take drugs for example: it's never guaranteed a drug will work, therefore many different drugs that treat the same illness are manufactured as alternatives, should the first trial not achieve the desired outcome. Doctor and patient both hope the drug will work, but if not "come back in two weeks and we can try the back-up drug". Likewise, when going into surgery, it is never guaranteed that there will be no complications and that you won’t end up vegetated on the operating table. Hence the creation of consent forms, information leaflets and protocol to recite the common, significant and material risks likely to affect the individual before going into the theatre. Risk, chance, uncertainty, hope, and unknowingness are eminent forces in hospitals - most of us just try really hard to block them out.
I asked Jacob about where he feels the place of hope and uncertainty lie in a hospital and healthcare: “There is a lot of hoping it - the treatment - will work because of course, there’s always the chance it might not. When we are diagnosing, again, of course we really hope we are right and hope it isn’t the worst-case scenario but we never know for sure. And that is the uncertainty”. Ben corroborated, saying: “In moments I have to make really difficult decisions, I often have moments where I go ’I really hope this works because I don’t know what I’m going to do if it doesn’t’“.
Nafisa informed me that hope plays a huge role in end-of-life care, and on occasion can make things even harder when communicating with patients’ families: “Sometimes there are patients who we really think are going to die, but then they might just wake up. The problem is, when that does happen, it makes it harder to have conversations with the families because it confirms that uncertainty. We will tell the families that there is a high chance that they [their loved one] could die from this disease, but we don’t know for sure. But as soon as you say that, you are essentially giving them hope which can make it harder for them if the former occurs.“ In this way, hope and uncertainty can become hurdles and hindrances in the process of acceptance, further evidence of their omnipresence within hospitals.
Tamsin supported this, saying: "There's hope and uncertainty in everything we do, a lot of medicine and health is pure luck - despite all the endless technologies we have. For example, I might have two patients with very similar physical features, very similar medical and family history, the same allergies or lack of allergies, have similar baseline stats and yet, where one drug may work wonderfully for one patient, on the other patient, they might get quite bad side effects or it may simply not work. Likewise, the exact same protocol and sequence of events may happen in the operating theatre and yet there might be a complication with one patient, and no complications with another. The family will ask what happened? Why did that happen? And sometimes the best we can say is ’it is a known risk, we don't really know why but it does sometimes just happen’". In both this example and Nafisa's, 'hope' is born from randomness, from an anomaly. Ironically, it seems that 'hope' can arrive not just when biotechnology saves all, but also when it fails most and saves one.
Anaesthetics is a prime example of a speciality that is founded on both intense precision and uncertainty. While it involves copious amounts of calculations, it is also largely based on estimates. Factors such as your weight, age, how painful the surgery is expected to be, the duration of the surgery, and also your preoperative exposure to nervous system depressants (e.g alcohol or painkillers) are all considered when calculating the dose of anaesthesia. However, it's always hard to know exactly how the patient may react and what their tolerance of anaesthesia is. For example, with sedatives such as Propofol, high levels of anxiety may cause that particular patient to require a higher dose. While the risk is low, MedicalXpress reports that there is around a 5% chance that one could experience anaesthesia awareness during surgery. Despite this however, most people take this risk as it is clearly better than being fully conscious while going under the knife. Moreover, an anaesthetist’s main role during surgery is to monitor the patient such that any unforeseen fluctuations can be managed. In some ways then, an anaesthetist’s role in the operating room is to be on stand-by for whatever uncertainties may arise.
Furthermore, an NIH article by Charlie M. Wray and Lawrence K. Loo published in 2015 asserted that “much of medicine is practised in shades of grey rather than black and white“. The prevalence of these uncertainties and dilemmas often challenge physicians, especially those who have just started out. Wray and Loo write that “many enter medicine for its objectivity and scientific rigour" and “in medical school, only one correct answer exists in an examination“. However, consequently, this seldom “mimics the greyish hues of the clinical environment“. Upon asking Jacob about his transition from medical school to a hospital, he said that "it was quite overwhelming", explaining that "in med school most things are very scientific, molecular, anatomical and wrong or right. But, when you get on the ward, unsurprisingly, it's very different. At the start I felt like all my patients were ticking timebombs and that I was constantly trying to diffuse bombs - albeit minor ones. A lot of medicine is putting safety nets in every place possible." Likewise, Nafisa said that when she was in medical school the “pivotal role of hope” hadn’t occurred to her, yet since arriving on the ward, she realised how much she depended on hope and noticed the ubiquity of uncertainty in healthcare and hospitals.
A prime example of these “shades of grey” can be seen in the existence of ‘medically unexplained symptoms’. Medically unexplained symptoms are real physical symptoms experienced by the patient, however, have no medical cause that can be found. Medically unexplained symptoms are very common – according to the NHS, they account for up to 45% of all GP appointments and up to half of all new visits to hospital clinics. In many ways, medically unexplained symptoms are a direct embodiment of uncertainty in healthcare, while also highlighting the limits of the objectivity and the scientific precision in much of medicine.
When one thinks about it, healthcare is a profession that deals with bad luck and chance. In micro form, orthopaedic surgeons swoop in when you have had bad luck, fallen off your bike and broken a bone. Writ large, much of chronic sickness is luck. Take cancer for example - need I say more? Despite identified risk factors such as family history, exposure to carcinogenic chemicals, and lifestyle factors, often it is still hard to draw a direct link when it comes to the causality of cancer. Yet - oncology exists to handle it - to deal with people's bad luck.
Chance, luck, uncertainty and hope are all interconnected and can be quite unnerving a lot of the time, both for patients, doctors, and all those on the periphery. However, the plethora of medical research, existence of evidence-based medicine, and healthcare professionals' intense training and specialised knowledge is what provides hope in healthcare and medicine in the battle against the uncertainties of health and disease.
Personally, I find the presence of uncertainty and hope in healthcare renders it all the more intriguing. No matter how much biotechnology develops in order to aid diagnosis, improve treatment, identify germs and track disease progression, still much is unknown, uncertain and liable to change at any given moment. It seems that human health, and all the uncertainties within, are constantly testing technology and catalysing innovation as they remain one step ahead in the arms race between pathogen and scientist. Lastly, if the mystery of the human body and disease is anything to go by – perhaps this uncertainty will always be there and perhaps, the only drug that will ever work is hope.
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