Conversations: Maggie Jackson

This episode explores the theme of embracing uncertainty, especially within the medical field, through a discussion with Maggie Jackson, author of "Uncertain: The Wisdom and Wonder of Being Unsure."

1. Uncertainty can lead to heightened attention and sharper cognitive functions.
2. Embracing uncertainty requires a balance between knowledge and openness to new experiences.
3. Surgeons and medical professionals often face 'adaptive expertise,' needing to balance routine knowledge with the unpredictability of each case.
4. There's beneficial stress associated with uncertainty that can lead to personal growth and enhanced problem-solving.
5. Developing a tolerance for uncertainty can improve mental health and decision-making capabilities.

1: Introduction

Emily Silverman introduces the topic of uncertainty in medicine and the book "Uncertain" by Maggie Jackson. This segment sets the thematic tone of the episode, focusing on how uncertainty impacts personal and professional realms. Emily Silverman: "Today, we're diving deep into the concept of uncertainty in medicine."

2: Uncertainty in Surgery

Jackson discusses a surgical scenario to highlight the critical moments where uncertainty plays a significant role. The detailed description offers insights into the tense moments that surgeons face. Maggie Jackson: "The senior surgeon keeps urging the junior doctor to hasten."

3: Defining Uncertainty

Maggie Jackson defines different types of uncertainty and discusses their relevance in everyday situations, providing a broader understanding of the concept. Maggie Jackson: "Aleatory uncertainty is about the unknowns that we cannot predict."

4: The Neuroscience of Uncertainty

Exploration of how the brain reacts to uncertainty, emphasizing the physiological and psychological responses that enhance cognitive functions. Maggie Jackson: "Uncertainty is actually a moment when the brain is very receptive to new information."

5: Practical Implications and Strategies

Discussion on practical strategies for embracing uncertainty in professional settings, particularly in medicine, to improve outcomes and personal growth. Maggie Jackson: "Adaptive expertise involves being curious and skeptical, even in routine situations."

1. Practice mindfulness and presence in daily activities to enhance tolerance for uncertainty.
2. Engage in activities that challenge your routine to boost cognitive flexibility.
3. Apply a 'beginner's mind' approach to complex problems to foster innovative solutions.
4. Encourage open discussions about mistakes and uncertainties in professional environments to enhance learning.
5. Incorporate regular pauses and reflective practices into your daily routine to better manage stress and uncertainty.

In our 50th The Nocturnists: Conversations episode, Emily speaks with Maggie Jackson, award-winning author and journalist, about her book "Uncertain: The Wisdom and Wonder of Being Unsure." Maggie describes the neuroscience of uncertainty, the benefits of curiosity and slowing down, and findings from her interviews with physicians and surgeons about uncertainty in medical practice.

People

Maggie Jackson, Emily Silverman

Books

"Uncertain: The Wisdom and Wonder of Being Unsure"

Guest Name(s):

Maggie Jackson

Content Warnings:

None

Emily Silverman
I study health insurance. Cause you're crazy. I'm a glutton for punishment. That's right. That's our kind of crazy.

At trade offs, we talk to people neck deep in data. 18% of our vaccine was going to black and Latinx Chicagoans, even though Chicago is 59% black and Latinx. To tell us what we know and what we don't. We used science to make driving safer, and we did not do that with firearms. So that we can tell you.

Subscribe now to trade offs. Support for the Nocturnist comes from the California Medical association. At the Nocturnist, we are careful to. Ensure that all stories comply with healthcare privacy laws. Details may have been changed to ensure patient confidentiality.

Maggie Jackson
All views expressed are those of the person speaking and not their employer.

Emily Silverman
You're listening to the nocturnist conversations. I'm Emily Silverman. In an era where certainty is often prized above all else, embracing the unknown can be a revolutionary act. Today's guest, Maggie Jackson, an award winning author and journalist, invites us to rethink our relationship with uncertainty through her new book, Uncertainty the wisdom and wonder of being unsure. Nominated for a National Book Award and celebrated on numerous best books of 2023 lists, uncertain has captured the attention of people everywhere, although I was especially interested in the sections that address uncertainty in medicine.

As you may know, the nocturnist is currently working on an entire series on the topic of uncertainty in medicine. So I was really grateful to have the opportunity to chat with Maggie about her experience in interviewing surgeons about uncertainty, the way that we handle uncertainty in diagnosis and the value of slowing down and even daydreaming in facing down the unknown. Maggie did such an amazing job bringing together science, psychology, and even poetry in this book. So before we dive into the conversation, let's hear a passage from uncertainty. Here's the last big thing that needs to be divided, Moulton whispers to me as the surgeon exposes his final target, the crucial bile duct nestling in the organ's recesses.

Maggie Jackson
The cancerous half liver is nearing removal, the five hour operation approaching completion. The senior surgeon keeps urging the junior doctor to hasten. He makes a move. A stapler bites down on flesh. It was a critical moment, Carol Ann Moulton explains later, and he divided it like it was all routine.

And then he halts, saying, hold it. The small talk ceases. A sweat darkens his cap, and a ringing phone goes unanswered. Don't cut, he orders, stumbling on an unexpected glimpse of bile duct. He suspects that a minute earlier he may have done the unthinkable and severed the duck's main stem.

In medicine, such incidents are called never events, errors that shouldnt ever be made. Has he ridden blindly into danger, mistaking the irreplaceable for the expendable? This time it was just a frighteningly close call. Failing to clean off enough of the surrounding tissue, he was working a few millimeters off target and sliced through an innocuous blood vessel, mistaking it for his true mark. That wasnt the bile duct, that thing before, he murmurs, swiftly recovering his pace.

This is the bile duct, actually, yeah. The mistake we made was we are too far into the right side. Over a lunch of chowder and chili in the cafeteria, he and Moulton unsparingly probed the incident. I clearly cleaned off the wrong structure, he admits. That could have been a landmine, she accuses.

You didn't check it? I didn't feel comfortable. I have to admit that. He says he had barreled into the crux of the operation, assuming success was a given. He had clung to his certainty, the badge of the old school expert.

Shifting uneasily in the lunchroom, he admits a sense of shame while repeatedly defending his commitment to the fluency he believes is his due. You take pride in being quick, she says. Yes, a lot of people do, I think. She looks down, pensive. That's the system we make, she says.

Emily Silverman
I am here with the wonderful Maggie Jackson. Maggie, thank you so much for being here today. It's wonderful to be here. Thank you. So, Maggie, as you know, we here at the nocturnist are doing a series on the topic of uncertainty in medicine.

So I was thrilled when I received your book in the mail, uncertain. The wisdom and wonder of being unsure. Uncertainty, I have found, is such a broad topic and such a broad concept. There are many definitions for what uncertainty is. But where have you landed?

If you were pressed, how would you define what is uncertainty? There's a lot of debate, but generally people think that there are now two main kinds of uncertainty. There's, first of all, aleatory uncertainty. That's the uncertainty or kind of a shorthand for the unknown or what humans can't know. So we gain a toehold on likelihood of, you know, the storm landing at 09:00 a.m.

Maggie Jackson
or something happening through probabilistic modeling, et cetera. But aleatory uncertainty is what we can't know. We really don't quite know. And then there's epistemic uncertainty, which is our uncertainty, psychological uncertainty. And that's a topic that, believe it or not, is actually gaining new attention for almost the first time.

It's been sort of the poor cousin to modeling and probability reasoning. Our uncertainty is really, in a nutshell, our human response to the unknown, and it's the recognition that we reach the limits of our knowledge. You did an incredible amount of research for this book, traveling and talking to all sorts of different people about uncertainty. Something I've been thinking about is what does uncertainty feel like? Or maybe the flip side is, what does certainty feel like?

Emily Silverman
You talk about one study where these metaphors are used for uncertainty, like darkness and lostness and fuzziness, but also realms that beckon. So wandering, exploration, wilderness. I'm wondering if you talked to people much about this and how you think about the way that uncertainty feels in the body. Yeah, I think that's interesting. And actually, as I've traveled around talking to people about this book, sometimes I ask people what's the one word they come up with when they think about uncertainty?

Maggie Jackson
And really, it's honestly, in and around angst, very few people come up with positive ideas about uncertainty. But when we begin to think about it, as you indicated in these studies of metaphors associated with uncertainty, there is a sort of attention involved. It's highly related physically and psychologically to curiosity or to wonder. And yet, at the same time, it's also an uncomfortable, challenging feeling. And in fact, it's challenging even when we're curious, which is really interesting.

So as far as how it feels in the body, that discomfort is really important because although we want to retreat from uncertainty or eradicate it quickly, because we, as humans or organisms, were evolved to need and want answers, you know, bottom line, you don't want to remain in indecision or irresolution. But at the same time, new studies now show that that uncomfortable nature, the unease of nature, is actually beneficial because it emerges from a stress response. The stress involved with meeting something new, ambiguous, unexpected, our body and brain kind of spring into action. And so your heart might race or your cortisol levels rise. But then, at the same time, and this is where the new science comes in, actually, your brain, with uncertainty, becomes more receptive to new data.

Your working memory is bolstered and your attention is sharpened. In fact, one really fascinating recent study interviewed doctors after they finished clinical shifts and found that the times when they were uncertain, when they're meeting something new, were associated with heightened attention, as the neural studies show, and also with more deliberate, intentional, looking forward to muster resources. So all of what I'm talking about is related to what scientists call arousal and I call wakefulness. Uncertainty is actually the moment when the brain is telling itself there's something to be learned here. As the neuroscientist Joseph cable told me, you know, it's really a gateway moment.

It's a signal that the time for autopilot has ended. And now it's important to update your understanding of the world. And so you are in between. You are uncomfortably in the liminal. But that's an invitation, not a moment when we should retreat.

Emily Silverman
I found the neuroscience behind this to be so fascinating. You were writing about how the brain is a predictive machine and how sometimes we suffer these minor hallucinations, like the phantom buzz of a phone or the imagined smell of smoke, which are simply times when expectation triumphs over the senses. And I was thinking about all those times that I've been in the shower and I've thought I heard the phone ring, or I thought I've heard my baby crying, and how the brain is always trying to anticipate what's coming next. And then when there's something unexpected, and you use an example in the book, you use the phrase a very happy war. And the word war comes very unexpected because you don't traditionally associate that with the word happy.

So you do. You feel that glitch of surprise in your brain, but then you go on to say something even more interesting, which is, aside from causing arousal, wakefulness, a sense that, ooh, something's different here. I need to update my knowledge. You say we actually get a dopamine hit from this. In other words, you say the brain treats a nugget of new data, or even the anticipation of one, not just as a means to an end, but also as something worthy in itself.

Can you talk about that part of it? It's really interesting. As you mentioned, there are two things going on. First of all, uncertainty is highly related to the epic chance. The invitation that I was just mentioning is related to that prediction error, which is our minds, our brains, reality check on the constant autopilot that we need to go through our days.

Maggie Jackson
You operate through assuming and expecting, because whatever you've learned in the past equips you to understand that your driveway isn't going to be in a new place when you drive home, etcetera. Alongside that is the root, basically, of curiosity and wonder and investigation. Whether or not we know whether something's utilitarian, just the mere expectation of, or a signal or a sign of information, news of a new bakery in your town, you don't know if it's bad or good, but you're curious because you like bakeries and cake. So dopamine is not just a. A sign that something's positive.

It's actually a sign that something is better or worse than what we already have. And I think that that's really important because that's how babies learn. No surprise, no learning. As one neuroscientist told me, they gravitate toward objects that are surprising. They don't know whether it's going to do them XYZ or it's going to improve their sats, etcetera.

We are so outcome oriented in this world. You worry about what your score will be or what the boss will say, or whether you'll get that bonus. Really, it's important to listen to the willingness within us to investigate for its own sake, because then when we become more open to the world, and this is one reason why outcome orientation actually impedes our ability to pick up on uncertainty and to pick up on the invitation to learn. In other words, outcome orientation, what people call reward based distraction, actually stokes the fearfulness which is getting in the way of our openness, our wakefulness. One study of tennis tournaments found that at the very highest levels of play, Wimbledon and us Open, etcetera, found that the trophy is prominently displayed on the side of the court.

The champion struggles because they tend to think I'm not doing well enough, or they're reminded of that outcome and then they recede from being in the moment. The mindfulness, which is uncertainty. Uncertainty is the spur both to move us into that moment. And uncertainty is also a space of possibilities that we should and can use to inhabit a question and again, be present to the possibilities. As part of your research, you spent a bit of time with surgeons, as we heard in your opening reading.

Emily Silverman
I love the Emily Dickinson quote that you included in that chapter, where you say surgeons must be very careful when they take the knife underneath their fine incisions. Stirs the culprit, life. What did you learn about uncertainty from these surgeons? Well, I wanted to meet with and spend time with surgeons because they are, in essence, sort of a stand in for all of us. Expertise in our culture is seen as knowing just what to do, walking into the boardroom, walking into the operating room, and just having an instant answer.

Maggie Jackson
We can see this from pundits on tv to how we expect a leader to operate. I wanted to be with surgeons because I also was asking whether uncertainty has a place in the most high stakes, most high pressure moments. Because when I was writing this chapter, friends, family, whoever knew I was writing about surgeons and uncertainty, said the exact same thing. Well, I wouldn't want a surgeon who's unsure. And what I learned was that there are really two forms of expertise, routine and adaptive.

So it all fits in a little bit with the predictive processing that we operate from most days. But we accrue practice through thousands of hours of learning and knowledge. And in doing so, we create mental models and heuristic shortcuts so that at a cue, at a signal, the doctor hears chest pains and thinks heart attack, likelihood, etcetera. It's a very important stage of expertise, but at the same time, many people easily, I think all of us do, fall into a kind of complacency when we reached a certain level of prowess, when we do know what to do. And that tends to lead to something called carryover mode.

That means applying the same old problems even after you do meet something new and complex, not listening to the signal of uncertainty. You know, I can see this in reporting, you know, reporter who's really, really good and just, you know, has seen it all and falls into that routine expertise. But in contrast, adaptive experts inhabit the question. They, on average, spend more time diagnosing a new complex problem than even novices do. So the adaptive expert wades in and looks at more options on average, and then tests and evaluate those options.

And I'm talking about just a few minutes of time. This is not hours long process. But to be an adaptive expert, you have to do two things. One is to be curious and skeptical, even in routine, to expect the unpredictable at all times and not wish and hope for familiarity all the time, and hope it's easy and etcetera. And then secondly, over the course of their careers, they take on harder cases.

They tend to work at the edge of their knowledge. So you can kind of see the picture I'm painting or portraying of the adaptive expert as someone who has an approach to a life that accommodates and harnesses uncertainty at all times. I talk about it as having your knowledge lightly held, not being entrenched in what you know, but in, in essence, always extending what you know. There's a flavor of the beginner mind here, and I learned so much about what it means to know from that experience and from also the humility it takes to be an expert who's willing to harness unsureness, a certain humility that we in many, many fields are under pressure to ignore or not cultivate. You talk about the benefits of slowing down when we encounter uncertainty.

Emily Silverman
So for surgeons, they might fall silent or deepen their focus. It might look like hesitation, but in fact, it's a controlled effort to reconcile with some rupture in the pattern that they've observed beyond surgeons. You also talk about this famous study from 2003 out of Harvard where a bunch of anesthesiologists were in a simulation lab trying to solve a clinical problem. It was a person whose oxygen was going down, and the reason was because their breathing tube was blocked. And the experimenters watched all these doctors scramble and try to figure out what was wrong.

And it was the elite few anesthesiologists who slowed down and considered alternatives who saved the patient. So talk about slowing down. How is that beneficial to us? Uncertainty, as John Dewey, the philosopher, said, involves a certain kind of execution. In other words, uncertainty is opening up the space between question and answer.

Maggie Jackson
So it does involve a slowing down or a pause. And it seems as though it can't be dynamic, it can't be active if we're pausing. But we so often in this efficiency oriented society misconstrue, quote unquote, doing nothing and overlook the true activity that's inherent. You know, I'm talking about everything from sleeping on a problem which is actually using time and the suspense of uncertainty to get to a better answer to gain insight. And I'm talking about pausing just momentarily, which is extremely important for the kind of deliberation that the adaptive expert undergoes.

Even just a daydream, a natural way of asking what if? Questions is very much uncertainty in action. And when you're daydreaming, actually, the perceptual decoupling that you undergo is absolutely fascinating. I mean, your senses truly begin to tone down so that the different networks of the brain related to looking inward begin to fire up. One scientist calls this looking outward versus looking in, and they can't be done at the same time.

So I think the pause is really important. I wrestled with that quite a bit, not only because it does seem like a negative in our lives, but also because it's sort of hard to define. But then when I began looking further, I could see the beauty and the importance of pausing in all of these ways that I've just talked about. It's also really important in our society because I think we misconstrue one tempo as sufficient speed. And that is basically ignoring all of what I'm talking about in and around uncertainty, basically, you know, accommodating or inviting different definitions of cognitive activity to be part of our repertoire.

Not knowing and liminal and seeing the gray. You know, life is not binary and neither is thinking. Tempo is a spectrum, not just speed. And so I think this really opens up our world. And if you could be uncertain productively or skillfully, you can actually think and rethink.

You can see multiple possibilities. You can be inclusive of multiple perspectives. So that gave people courage, and many, many people in psychology and also in medicine have told me it's liberating.

Emily Silverman
I loved reading about this family medicine residency program at Central Maine Medical center. The leaders there noticed that the students were being attracted toward more acute care specialties. Nobody wanted to go into primary care. Nobody wanted to deal with complex patients with chronic disease. And they pinpointed the problem, which was this fear of uncertainty, and then developed this curriculum to help them build up their tolerance of ambiguity and shift their culture, shift their perspective.

And I was thinking about the different types of uncertainty in the OR, for example, which is very life or death, moment to moment, versus in something like a family medicine clinic, where somebody online, I think, recently described the experience of being a family medicine doctor as, imagine you have a day of work that consists of 20 meetings back to back, where you have to be present, listen, make an assessment and a plan, make the right decision, and then write up a report with the deliverables for each meeting, and do that back to back 20 times in a day. And it just made me think about what you were saying about the importance of pausing and the importance of silence and how there is work happening in silence. We think of this in the audio medium when we're putting together our storytelling. Sometimes a beat of silence can feel very active. And so I'm wondering if you've thought at all about the outpatient setting, the speed of it, and, like, how do we even begin to try to incorporate some of those pauses into the work when it feels so impossible?

Maggie Jackson
Well, I do know that Ronald Epstein, who studies mindfulness in medicine, changed his entire practice to accommodate pauses just after seeing one patient. He'll pause slightly before going into the next room. And it's really interesting, because very often I found in the brain research that pausing or silence is related to higher cognitive activity than actual activity associated with goal oriented, trying to figure something out, et cetera, making a decision. So when the mind is supposedly at rest, it's highly, highly active. And, you know, this can be seen in the pauses between measures of music.

You gain 20% or more memory encoding if you pause between spates of learning. That's changed my life, because instead of going from interview to interview, you know, as I'm doing research and talking to people, I now put time in for pausing to basically digest the experience and let my mind do what it will to curate that information. And again, the neuroscience is amazing. So I think that people in healthcare and medicine can interweave pausing and experiment with different ways to approach time. I know that one study by the same surgeon who was my guide in Toronto, the one who studies surgical judgment and is quite renowned, Carolyn Moulton, did an early study about spacing out learning.

And she found that the surgical students who had learned how to repair a blood vessel over the course of a month versus in a big one day cram it all in kind of workshop, came out far, far better at that important skill. And there was struggle within the spaced learning versus masked. Masked learning seems easier, like cramming, get it all done, tick off the box. But at the same time, these tempos and seasons of actually forgetting a little and then struggling to get back into the knowledge and also sleeping on a problem and coming up with insight, I mean, all of these are scientifically proven outcomes from pausing. Again, it feels uncomfortable, but it's actually, in the long run, a way to create deeper meaning.

The bottom line is that we can adopt some of these strategies in very small slices. You mentioned that any given person's ability, willingness to tolerate uncertainty, may depend on different factors. It may depend on their personality, it may depend on time, place, context. What have you learned about who is good at uncertainty? Who is not so good at uncertainty?

Emily Silverman
What types of personality traits should we be looking at? I know there's a couple even measurement tools like quizzes you can take to quiz yourself and locate yourself on that spectrum, but talk a bit about that. The kind of discovery of tolerance, of uncertainty as a personality trait occurred in about 1949. A psychologist at Berkeley gave people, really, they were shown flashcards of an animal that at the beginning was a picture of a cat, and over the course of the flashcards, it became a dog, you know, with these little tweaks to the drawing. And she found that in the mix, there was one group of people who just wouldn't relinquish the idea that this was a cat far into the assessment, when really they should have recognized they just wanted to hang on to the safe harbor of what they first knew.

Maggie Jackson
And they were rigid thinkers. They didn't want to escape from what they know into the unknown in this very small, small, microscopic way. She named that group intolerant of uncertainty. And so now there's a tremendous amount of research about this personality trait and how being intolerant of uncertainty shapes almost everything. We do.

People who are intolerant of uncertainty, as I mentioned, who see it as a threat, threat, actually are much more at higher risk for anxiety, which is seen as a fear of the unknown, but also for most other mental disorders. And so it's seen now as a lever for treating. And there are new interventions, gold standard randomized controlled trials, that show that by just targeting focus of persons intolerance of uncertainty, they can actually lower worry and depression and anxiety to levels in the normal population. So this notion of being intolerant, it basically means that people are more prone to rigid thinking and more prone to binary thinking. It affects how they argue, it affects how they see others.

Whereas tolerance of uncertainty is associated with curiosity, flexibility, with really being with another kind of personality dimension called open to experience one little other, you know, just to drill into the psychology for just a sec. More. It's really amazing that when you look at the curious personality people who are curious, the difference between being, hmm, little bit wondering, and then being actively curious, being more prone to express dissent, being more prone to explore the world, being really an adventurer versus just merely curious, is an ability to contend with uncertainty, to tolerate the stress of uncertainty. So this uncomfort, this awkwardness with being on the edge of what you know is also really important for curiosity. And it's not a picnic, it's not a bowl of cherries, but people who are curious and act on it really go forth despite that awkwardness.

But as the interventions show, we can raise the dial, we can be more uncertain. And I, for instance, took up open water four season swimming in the Atlantic Ocean or Rhode island during the pandemic. First of all, I'm not warm blooded. I don't really like surf, and I'm really a cautious person. But I found I loved it.

And long story short, I really think a great deal of that has to do with this daily dose of uncertainty. It spills over into the rest of your life. That's another way in which people in healthcare, I think, can strengthen themselves in and around uncertainty to take on new things in small ways, delegate more at work or try something new in your life, etcetera. It really actually spills over into contending with difficult situations. I love this story about taking up swimming in the ocean as an unexpected pandemic hobby, and how that daily dose of uncertainty spilled into the rest of your life.

This was a social activity because people gathered to do this. It became a global phenomenon in this sort of outdoor swimming. It's exercise, it's gloriously sensory. Swimming at dawn is just downright beautiful. But I couldn't figure out why.

It was joyful to the point of exhilaration. And it did take me a very long time to recognize that. In doing so, I'm constantly on the edge, because you can have the app that tells you the surf height, and when you get there, it's not really accurate. Or you can be in the water, and the conditions when you're looking at the beach are different 20 minutes later when you're midway through. So I remember once in our wetsuits, or maybe in the fall, and we were going in later than anybody else and standing on the beach, and one gentleman walked up to us and said, doesn't it make you feel alive?

And he wasn't dressed for swimming, but he knew that. He put in a nutshell. And I found that this ability to contend spills over in the rest of my life in so many ways. Just one of the main takeaways I've had from becoming more adept, or I don't like to say comfortable, because that's not the point. It's not easy street, but just becoming more adept and open to uncertainty is that when people are having trouble in life, a friend, a daughter, I don't know, a work colleague, it's so tempting, and I think so kind of revered in our society to rush in, even if they're grieving with the loss of someone, to rush in and fix it.

You know, you'll feel better tomorrow, or here's what you can do, or you should try to do this. And I used to be very much of that ilk, and now I find that their uncertainty is a place to be in together. I find that if I have a daughter who's upset, I now try to inhabit the question with her, which allows us to explore different possibilities instead of rushing to, say, fix it. I find that that is one of the most enriching experiences that I've taken away from uncertainty. For people maybe, who have adopted more of a rigid form of thinking, binary form of thinking, maybe that's inherent to their personality, or maybe that's been imposed upon them by chronic stress or information overwhelm, or whatever situation that they're in, how can we move the dial?

Emily Silverman
Is it the kind of thing where even seasoned doctors who have been in these patterns for years can work on themselves in this way? You know, should we take up swimming? Should we enter into some kind of curriculum? Or what are some ways that we can improve uncertainty tolerance in the profession? I would predict that we are coming to the day when both in clinical psychology fields and also in medicine, that practitioners will be routinely, if not have, a mandatory introductory, a core curriculum course that involves teaching tolerance of uncertainty.

Maggie Jackson
I think the state of the field is rapidly understanding scientifically how this can be done. We don't have the answers yet, but there are many, many ways in which people individually can explore contending with uncertainty differently and in a more healthy way. It starts with a change in mindset. It really does start with and understanding that uncertainty is not a disaster. If you don't know, it doesn't necessarily mean you're weak.

That's a really important part of it. It's okay to not have an answer. As one of the teachings that the main medical center faculty tried to help the young family medicine residents learn. And that was game changing. As one of the young residents said, when you are uncertain, then you're not set in stone.

You don't have tunnel vision. So that's something to work toward. This is a metacognitive exercise. It involves a little bit of watching yourself and your reactions to the traffic jam or to when things don't go well in a practitioner moment, the second thing we can do is we can expect change. Now, that seems so simple, silly, and so obvious, and particularly now when we're, you know, often very threatened by the many, many rising, rapid speed changes we inhabit now.

But that's the moment when we want to retreat into heuristic solutions or just wishes and hopes, assumptions that things won't change. When you walk into the Monday morning meeting and you expect more of the same blah, blah, blah, then you're more likely to miss out on the signal of uncertainty and the nuances in the room. So it's very, very important to constantly expect that things will change. I see this constantly in the way people understand one another, that if I see a friend and I expect them to be the same, whereas maybe if I haven't seen them in a year, they're actually going to be kind of a different person. So I should be open to that and a little bit more observant, I think.

Also, leaning into stress is really important. If we can begin to understand that there's such a good thing as good stress. Let's associate that with uncertainty, because that moment of arousal is just too important. It's an epic chance to move in a different way, away from fear and toward curiosity and wonder. And then finally, it is really important to constantly try new things, because we do live our lives in the sort of mindset of autopilot and familiarity for very good, natural reasons.

You don't need to learn every morning how to tie your shoes, etcetera. But at the same time, we really should look for tiny new ways. I mean, I've started studying French for the first time online in many, many, many years, and I thought it would be onerous. I have to speak in a french country, and I'm expected to at least say a few words in French. I thought it would be really onerous and really bog me down.

And I find that I'm making mistakes right, left, and center, and it's just, just wonderful. I love it. And so these little things can really help us. Well, I think that's a wonderful place to end. I just want to thank you so much for writing this book, and particularly all of the medical stories and examples in here have been so wonderful to read, and I'm sure will inform the project that we put out on uncertainty in medicine.

Emily Silverman
So I just want to say thank you so much. I have been speaking to Maggie Jackson, the author of Uncertain the wisdom and wonder of being unsure. Thank you again, Maggie. Oh, you're welcome. Thank you.

This episode of the Nocturnus was produced by me and Sam Osborne. Sam also edited and mixed. Our executive producer is Ellie Block. Our head of story development is Molly Rose Williams, and Ashley Pettit is our program manager. Original theme music was composed by Yosef Monroe, and additional music comes from Blue Dot Sessions.

Anoctrinos is made possible by the California Medical Association, a physician led organization that works tirelessly to make sure that the doctor patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org dot. The nocturnus is also made possible by donations from listeners like you. Thank you so much for supporting our work in storytelling. If you enjoyed this episode, please like, share, subscribe, and help others find us by giving us a rating and review in your favorite podcast app.

To contribute your voice to an upcoming project or to make a donation, visit our website@thenoctrenist.com. i'm your host, Emily Silverman.