Random Riffs
Disregard of Uncertainty: Willful, Fearful … Or Just Plain Dumb?
January
29
2010
"When trouble arises and things look bad, there is always one individual who perceives a solution and is willing to take command. Very often, that person is crazy."
Dave Barry, Miami Herald I began my working life as a physical scientist in the metallurgical labs of the Steel Company of Canada. I was a metallographer, the forensic pathologist of things metallic, and my job involved figuring out why steel misbehaved and how it might be persuaded to behave better. We knew steel really well − not surprising given that we had created it. We were able to predict what would result from changes in chemistry; heat treatment protocols; hot and cold processes of manipulation. It was an “if-this-then-that” kind of world; one of predictive models and of comprehensible cause and effect relationships. And the glory of it all was that steel was completely indifferent to our ministrations — if we didn’t get it right the first time, we could always go back and mess around with things until we did.
At a point in time, I traded the “if-this-then-that” world of the physical sciences for the “if-this-then-maybe-that” world of the social sciences. Whereas we know steel well because we created it, we remain a mystery to ourselves because we didn’t. The maybe should make us humble and our claims more modest. But it often doesn’t and we choose to ignore the uncertainty that attaches to the maybe and say more than we know, persuading ourselves – and our clients − that if we make this kind of intervention in a social system we will get that kind of outcome. And the consequences of this brand of hubris are not victimless crimes – unlike steel, people have minds of their own and are not indifferent to our ministrations. I put it all down to method envy. And no gender bias in this brand of envy!
As I pondered the delicate matter of maybe, I recalled reading Jerome Groopman’s “How Doctors Think” where he says that, on average, physicians will interrupt patients describing their symptoms within 18 seconds and will often, in that time, diagnose and decide on the best treatment. (A more recent study reports that this number has jumped to 24 seconds. Who says docs aren’t beginning to take listening seriously?) There is a chapter in Groopman’s book titled, “The Uncertainty of the Expert” where he discusses the work of Jay Katz, a physician who teaches at Yale law School. Katz observes that “the denial of uncertainty, the proclivity to substitute certainty for uncertainty, is one of the most remarkable human traits.” And later, there is a “pervasive and fateful human need to remain in control of one’s internal and external worlds by seemingly understanding them, even at the expense of falsifying data.”
I’m not into doc bashing here – some, at least, seem to acknowledge the vexed matter of uncertainty and the world of maybe. I Googled “doctor-patient conversation” and came across an essay by Paul Haidet, MD, a faculty member at Baylor College of Medicine in Houston. As an educator, researcher and amateur jazz historian, he says that improvisation is in the nature of patient-physician communication which is “typically unscripted and constructed in the moment. A patient-centered care ideal calls for adjustments to and departures from these patterns in response to concerns and perspectives voiced by the patient.” He goes on to quote Stephen Nachmanovitch, PhD, a violinist and scholar on creativity and the spiritual underpinnings of art, who describes the tension between medical training and patients’ novel contexts.
In real medicine you view the person as unique—in a sense you drop your training. You are immersed in the case itself, letting your view of it develop in context. You certainly use your training; you refer to it, understand it, ground yourself in it, but you don’t allow your training to blind you to the actual person who is sitting in front of you. In this way, you pass beyond competence to presence. To do anything artistically, you have to acquire technique, but you create through your technique and not with it.
Several years ago I was approached by Balfour Mount, Eric M. Flanders Professor of Palliative Medicine, McGill University, who invited the musicians of Getting in the Groove and me to do the final plenary session for an international congress on palliative care which he chaired. In an early conversation with Balfour I recall him saying this to me. “Those of us who care for the dying are faced with death all the time, but we have to remember that this death is this person’s only death; it’s utterly unique to him or her. So we have to do it their way, not ours − which means we have to listen.” In the course of the session with about 1500 delegates at the Palais de Congres in Montreal, I quoted the jazz pianist Keith Jarrett who said, “If you can’t listen, you can’t connect.” After we were done, Balfour, by way of a benediction to end the conference, improvised on Jarrett’s comment by saying, “If we can’t listen we can’t connect and if we can’t connect we can’t heal.” At dinner the previous night, he had talked of the difference between healing and curing and pointed out that we can live cured and die healed. A wonderful and provocative insight.
So, let’s get back to “If this then maybe that.” By acknowledging the uncertainty implicit in maybe we prepare ourselves for a move out of our comfort zones. Maybe something other than the hoped-for that will get us into an uncomfortable zone where we may actually learn something new. These are the risks we take when we engage in the transformational conversations I’ve been going on about in recent Random Riffs. Here’s an example of what can happen when uncertainty is acknowledged.
During the course of one of the monthly conversational jam sessions I had with my consulting colleagues and spoke of in an earlier Random Riff, one of the consultants told this story. Kathy reported that she had been meeting with the management team of one of her clients where they were planning a large and complex project. Things were not going well. They were, in fact, going rather badly. Confusion and uncertainty reigned and she wondered what to do. Although she was there to help bring order out of the confusion (and getting paid big bucks to do so) she felt that not only was she not helping, but rather, feeling out of her depth, she was actually contributing to the confusion. What to do? Well, she decided on a courageous course – she announced to the client that she had no idea what was going on and had no idea how to help put it right. And the client − all six guys of the management team − were relieved and delighted. They had no idea either and were grateful that Kathy had made the call. Acknowledging the uncertainty turned into a liberating experience for everyone. They relaxed and got on with the job.
And by telling her story at that conversational jam session, Kathy liberated us as well. We live much of the time on the border between what's known and what's not known and it’s a good idea to recognize and acknowledge the difference. Let’s face it, there are times when we don’t know what the hell is going on and if we pretend that we do, we make matters worse. The temptation, in these circumstances, is to keep talking in the mistaken belief that talking is the same thing as thinking. It isn’t! And it’s useful to keep in mind that just because we know something doesn’t make it important.
