The Positive Power of Uncertainty in Medicine

Editors’ Note:  As students resume their studies, we’re taking a look back at when Dr. Hillary Kunins delivered the keynote address at Albert Einstein College of Medicine’s joint master’s degree ceremony for Einstein’s Clinical Research Training Program (CRTP) and the Einstein-Cardozo Master of Bioethics program in May. A CRTP graduate, Dr. Kunins is now assistant commissioner at the New York City Department of Health and Mental Hygiene and a clinical professor of medicine at Einstein. In her commencement speech, she explained why uncertainty in a healthcare career can be a good thing. Below is a transcript of her address, edited for length and clarity.

I want to spend my time with you today discussing uncertainty, which, for me, characterizes beginnings, transitions and inflection points.

During my early career, uncertainty haunted me terribly. But when I encounter it now—in myself, or in my work—it makes me know that I am tackling a deep issue, whether a professional decision or personal one.

Those of you graduating today are completing master’s in clinical research and bioethics. These different programs have equipped you with quite distinct frameworks and skills, yet both are fields that will equip you to tackle uncertainty—to make sense of it and to move past it, into opportunity and change—whether in a research study, with a patient over a clinical decision, as a teacher, or in some other way.

During my earliest career decisions, during the CRTP and my tenure at Einstein/Montefiore and at NYC Health Department, uncertainty worked for me.

Up into the Unknown

First, what has characterized nearly every professional transition for me is the sense of being at an inflection point, but not knowing exactly what the angle would be on takeoff.

One of the first inflection points was completing my residency in internal medicine, when I was uncertain about taking a job in primary care—which is what I believed I had been preparing myself for. This inflection ended up sending me off in a direction focused on substance use and addiction when I decided to take a job as a medical director at a methadone maintenance program.

Listening to my own uncertainty at that point helped me expand my focus. Although deeply uncomfortable at the time, it led me to opportunities and choices that I would not have had otherwise.

Mentorship to Manage Decision Making

I did not manage that uncertainty alone. Careful mentorship, particularly from Julia Arnsten [chief of internal medicine at Einstein and Montefiore], urged me to consider all options, to think about what alternatives might be like—and caused me to listen deeply to myself about the kind of position I sought.

Without mentorship, and serious and caring feedback, I could not have managed to move through uncertainty to new places. For me, these unexpected opportunities have turned out to be in the application of science specifically focused on substance use—first as a medical director, then as a researcher, then as a medical educator, and now as a translator of science into policy.

Renaming Uncertainty

During my training in the CRTP, I learned the word “equipoise.” Equipoise, for me, was a renaming of uncertainty into a more noble and dispassionate idea. A word and concept less fraught with emotion and imbued with possibility.

To ask a good research question, to design an ethical and rigorous study, the researcher ought to have equipoise—that is, really not know the outcome or answer.

But I think it is critical to point out that one needs both empirical and ethical equipoise: would knowing this answer help improve health outcomes? And for whom? Would withholding treatment in a control group be ethical—that is, is there enough equipoise in the effectiveness of the intervention to warrant a placebo arm?

Public Health Examples

Finally, I want to share my experience in my work in public health and drug policy at NYC Health Department. As you all know, the country and the city are facing a serious epidemic of opioid overdose—one which has made us confront mistakes and failures to be uncertain, and to consider new policies about which there remain uncertainties. During some of these more difficult decisions, I try to remember the calm that the word “equipoise” lends.

When I joined the health department in 2012, there had started to be increases in heroin use, but what received national attention were sharply increasing numbers of overdose deaths involving prescription opioids. We were somewhat spared in NYC at that point. Nationwide, opioid prescribing had skyrocketed: propelled by real human suffering and pain, health professionals’ desire to relieve that suffering, but also and perhaps most significantly an aggressive strategy by industry to increase opioid prescribing.

Where there should have been uncertainty [in prescribing these medications]—there was none. And that is the error we are living with now. The safety claims of opioids for chronic pain was based on extremely thin evidence. In fact, a single retrospective study published as a letter in the NEJM in 1980 declared “addiction is rare in hospitalized patients,” and is cited now (in Google Scholar) more than 1,000 times. So, our error in the 1990’s was a failure of uncertainty: a failure to consider what we didn’t really know.

And now, 2017 brought the seventh successive year of increase in overdose deaths in NYC, up more than 100 percent since 2010. This rapidly growing problem—nearly unprecedented—has posed many uncertainties. Responses to the opioid crisis have included calls for a public health approach to the epidemic. But what does that actually mean? What combinations of strategies and approaches are best? How do we then wade through the scientific and ethical uncertainties such an epidemic poses?

Lifelong Lessons

The skills I learned from the CRTP inform so many of my daily decisions: What strategies have the highest quality of evidence behind them? Is the evidence sufficient to make a decision? If not, what other evidence is needed to do so? And here, I find we cannot make policy simply on science—but return in some cases to basic bioethical principles to help move from uncertainty to action.

I don’t want to leave you dwelling in uncertainty. I want you to take advantage of it—rename it as equipoise, if you wish—to be unafraid to ask hard questions, whether in your research, in your clinical care, in your teaching, or in your policy-making. Let it help you find and tackle the hard questions and believe you can find ways of answering these questions—with your colleagues, patients, students.

My sincere congratulations to all of you on arriving at this inflection point—I wish you all the very best for your next adventures.