This is the Drive Time Debrief, episode 217.
Hey guys, welcome to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today we're talking about something that sits quietly underneath so much physician stress, and that is uncertainty. Not knowing if you made the right call, wondering if you missed something, replaying decisions, just ruminating it into the ground long after the shift ends.
And if you've ever wished you could feel one hundred percent confident in every decision — I've been there — this episode is for you. Because unfortunately, here's the truth: medicine is not one hundred percent certainty. But confidence isn't built by eliminating uncertainty. It's built by learning how to tolerate it, and that's a skill we can all use.
So let's break that down. Medicine attracts people who value competence, precision, and getting things right, and that makes sense. Lives depend on it. But psychology tells us something important. Many of us struggle not with uncertainty itself, but with something called intolerance of uncertainty. This concept is well-studied in anxiety research, especially in work by psychologists like Michelle Dugas.
Intolerance of uncertainty means you believe uncertainty is dangerous, unacceptable, or must be eliminated before you can relax. Hmm. That's strong. Sound familiar, though? In medicine, that often shows up as excessive second-guessing, ordering just one more test for reassurance, asking colleagues repeatedly if you did the right thing, and mentally replaying cases late at night — not because you're careless, but because you care deeply.
Here's the kicker: uncertainty is not a bug in medicine, it's a built-in feature. Even the best-trained physicians work with incomplete information, evolving conditions, and the unpredictable human body, right? We always say that our patients don't read the textbooks. I mean, thank God for the authors of the textbooks, but let me tell you, there's a wide range in how these people show up.
So if your brain is demanding certainty before it will relax, you've created an impossible standard, and impossible standards always create suffering.
Okay, so let's talk about the rumination trap and why your brain doesn't want to let it go. Rumination — I think all of you are familiar with this term — is just thinking about something over and over again. Kind of like a cow ruminates on its cud. It eats some grass, it goes into its stomach, and then it regurgitates it and chews on it some more.
So that's what our brains do with thoughts, and rumination can feel productive. Our brains think, "Oh yeah, I'm problem-solving." And it says things like, "Let me just think through that case one more time. I should double-check my reasoning. What if I missed something?" But really, psychologically, rumination is not typically problem-solving.
It's anxiety trying to disguise itself as responsibility. And researchers study rumination a lot because this is a common problem. One such researcher is Susan Nolen-Hoeksema — I think I pronounced her name right, but if I didn't, I apologize. Some of her work found that rumination increases anxiety, and from the cognitive behavioral therapy model that we base a lot of our coaching on, we would agree, because thoughts generate feelings. They generate more emotion for us. And so if we're thinking a thought that increases anxiety and we rethink it, we're going to increase the anxiety further. It can worsen depression. It actually can reduce decision confidence and make it harder for us to make the right call the next time. We've seen this in clients that we work with — they may be very seasoned, experienced doctors, and suddenly rumination has created a situation where it's hard for them to make clinical calls that they need to make.
And it doesn't improve outcomes. It doesn't improve your outcome, and it doesn't improve the patient's outcome because that's already gone through the door. So let's let that sink in for a minute. The ruminating is not helping anything, and it's a mental replay loop that's stealing your evening, stealing your time with your family. It actually doesn't make you feel safer. It just makes you more exhausted. And the idea that thoughts can exhaust you — it is absolutely true. Thinking can absolutely wear us out.
Another key concept here comes from acceptance and commitment therapy, which was developed by Steven C. Hayes, and this is a very well-loved and well-respected form of therapy. There are some flavors of Buddhism in it. ACT talks about something called cognitive fusion — that's when your thoughts feel like facts. I certainly have been there, and am there sometimes regularly. I think we all are, where we're thinking and we're like, "How could someone ever think a different way about this?" Of course it's horrible that this happened to this person, and then you run across someone who actually doesn't think the same way you do.
So when we have this cognitive fusion, all of our thoughts feel like facts. Like, "I might have missed something" becomes fused into "I probably missed something." The fully fused version is, "I'm not a good doctor." See how fast that escalates? Like, I don't know — I feel like we've talked about this before, how we can go from zero to nuclear in about 50 milliseconds because of this way of thinking. And for people who value logic and reason, it's curious because it's not logical and it's not based in reason. It's just escalating, anxiety-inducing thoughts. The brain is confusing possibility with probability, and then probability with certainty. And any time we are one hundred percent certain of something, that's a time to really pause and say, "Hmm, what part of my brain is actually certain about this?" The certainty is oftentimes that emotional brain registering black-and-white thinking.
Once this happens — where we have confused probability with certainty — the rumination starts, and we're in for a long night of sleeplessness and worry, and we're going to start a cycle of just being exhausted and sad. And let's not do that.
Yeah. So let's talk about how to tolerate uncertainty without becoming careless, because I think our brains offer up, "If I just accept that this is uncertain, I just don't care anymore," or like, "I'm going to become careless. I'm going to be one of those people that are just like, 'Yep, good enough,' and carry on," and it's people's lives that we're talking about. No. Psychology shows the exact opposite. Like, first of all, is that even possible for you? If you're a person like this — this is what I had to ask myself — "I'm just going to go from a thousand to I don't care anymore?" That's not even possible for me, but I've tried it this way, and it's only driving me into the ground. So let's just talk about whether it's possible to be open to another way of doing it.
Psychology suggests that acceptance reduces anxiety, and less anxious brains probably make better decisions. You could be a better doctor if you weren't up all night ruminating about something that's already happened.
So one of the most helpful frameworks comes from, again, the acceptance and commitment therapy model. It's not that you need to eliminate uncertainty — you just need to make a little room for it. So here are three practical ways that you can start using.
The first one is to name the reality. Instead of fighting the uncertainty, acknowledge it directly. That would look like saying, "This case has uncertainty, and that's normal in medicine. It's normal sometimes to not know the diagnosis right away. Sometimes things have to develop." It might look like saying, "No physician has perfect information, but I'm going to do the best I know with what I have right now." Oh my gosh, if I could have said that earlier in my career and not judged myself from the retrospectoscope — because that's what I would do — that would have saved me a lot of suffering, because she was making the best decision with what she had at the time. She wasn't somehow able to read the future. And how can you possibly judge her for that when no one had all of the information at that time? And then it might look like saying something like, "Uncertainty is part of competent practice." It has to be, right? Medicine is part art. It's also science, but it is part art. There is not always a knowing. There's not always a right decision.
So this is called cognitive defusion — that means creating a little bit of distance from the anxious thoughts instead of just believing them automatically. It sounds simple, but you do have to retrain your nervous system to do this over time.
Okay, so the second tool we're offering is to set a rumination boundary. Ask yourself, "Is this problem solvable right now?" If it is, solve it. Great. But if it's not, then just know that you can contain this. You can schedule thinking time. It sounds crazy, but you literally can do this. For example, it can be, "Okay, tonight I'm going to get good sleep, and we're going to reconvene. We're going to put a pin in this and come back to it tomorrow at eight thirty." Just like you schedule things in your professional life, you can schedule your thinking time too. So when the thought returns later: "Hey, brain, I see you. I see that you are totally wanting to get into this rumination trap again, but I've already scheduled time for this. We're going to revisit this at eight thirty." That's not avoidance. That's containment, and containment can protect your energy.
So the third tool that you can consider using is to define good medicine realistically. We're so unrealistic about our expectations for ourselves and our expectations for the system. Obviously we always want to do better, but let's define what good medicine actually is. This one's huge. Many physicians operate with this unspoken definition that good medicine means perfect medicine. Good medicine means I never miss anything. Good medicine means I always catch it before the inevitable demise.
But that definition is impossible. When has that ever been possible in the history of medicine? Never. So many times you're comparing yourself — maybe it's your parenting, maybe it's your doctoring — to this impossible imaginary person in your head who is the perfect parent, the perfect doctor. That person has never existed. Nope. So I don't know — it's so crazy when I get called out about it myself, like, oh yeah, no wonder I feel awful, because I'm comparing myself to this absolutely flawless being who I just made up. Yep. She doesn't exist. Nope. No wonder I feel awful. It's so funny that she's available for me to negatively judge myself against. Yeah.
Okay, so good medicine is not perfect. It's not flawless. It is thoughtful and reasonable. Reasonable, people. That's what the courts recognize, that's what peer review recognizes, and that's what sustainable medicine requires. Boom.
If uncertainty makes you uncomfortable, that doesn't mean you're weak. It means you're human in a profession that asks for certainty in an uncertain world. But confidence doesn't come from eliminating uncertainty. It comes from learning that you can function well even when uncertainty is present.
And the physicians who master this — they don't just practice better, they sleep better, they worry less, they stay in medicine longer. And I'll leave you with that.
Thanks for today's episode, friends. If you found this conversation helpful, the best way to support us is to subscribe, so click that button now and give us a rating and review because it helps other physicians find this podcast.
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