A new kind of tension

There's an adage I often think about: "A physician's job requires the expression of  confidence. The researcher's role is to express doubt."

This was never more apparent than when I transitioned from the research environment into the clerkships of medical school. The language of decision-making had abruptly changed -- in the lab, a year's worth of experiments is summarized with "seems" and "suggests," and every assertion is carefully calibrated to acknowledge uncertainty and a high standard for proof.

As a student on clerkships, I couldn't quite wrap my head around the residents' ambitious plans for patients:

• "Check CBC, electrolytes, chest X-ray, EKG, oh, and, he needs a head CT."  

This use of "need" too often seemed careless to me, as if any patient could need a test that was almost certainly going to be normal, that in most parts of the world would never even be considered.

But in the residents' perspective, I came to understand the head CT was just an expected component of the patient's management -- it had nothing to do with likelihood ratios or pertinent life-threatening conditions that must be explored -- it was simply part of the story for certain patient scenarios, and couldn't be omitted without raising a lot of questions.

• "We should also check a TSH level."

Few patients ever needed a TSH level, as far as I recall -- this wasn't something that would hold up discharge, for instance. But checking thyroid function was often something that should also be done. Again, not because the residents had a firm grasp of the prevalence of thyroid disease in certain populations, but rather, because it demonstrated a thorough workup and, while not an essential or expected part of management, was nice for the attendings to see.

Over time, I gradually adjusted to this very nosocomial interpretation of "need" and "should." Now that I'm an attending, and the students' and residents' plans are a lot more hypothetical (until they get my approval), I'm hearing a little more "want" and "think" and "maybe." For me, it's a welcome return -- a language more in line with my background, and one that acknowledges the uncertainties of medicine.