Uncertainty: A Surgeon’s Lessons on Making Hard Decisions in Unclear Situations

Living with uncertainty is hard, but living without it is unrealistic. A framework to face uncertainty can help.

Photo by Piron Guillaume on Unsplash

Living with uncertainty is uncomfortable, but living without it is unrealistic.

To succeed in life, we must learn to coexist with uncertainty and thrive in its presence. It’s not easy or comfortable, but it is reality.

So here is what I have learned about dealing with uncertainty from one of the most uncertain careers: surgery.

This Isn’t Going to End Well

“This isn’t going to end well,” I told myself after I hung up the phone.

The Emergency Department had called me about a hemodynamically unstable 86-year-old woman who they were concerned needed surgery.

Operating on octagenarians is always risky, and operating on unstable ones is an order of magnitude more dangerous. People at the extremes of age have little physiological reserve, meaning it takes all their energy and health to get through a normal. Thus, they have nothing more to give when a big insult occurs.

I arrived in the Emergency Department to find a frail, elderly woman who looked every one her 86 years. Her blood pressure was well below normal, but more concerningly, her heart was failing to pump faster to increase blood flow as it should do in a situation like this.

I examined her and agreed with the ED doctor’s concern that she may need surgery, but my exam also brought to light other problems, like her swollen ankles and crackles in her lungs, the tell-tale signs of congestive heart failure.

Anesthetasising people with heart failure is risky. Even worse, putting someone to sleep when their physiologic collapse is caused by congestive failure and not a surgical illness is often fatal. If I put her under anesthesia and did not find something I could fix, she might never wake up.

The one certain factor was that she was dying. The uncertainty arose from the question of whether she was dying from heart failure or some other, more pressing issue that was complicated by her…