by Carolyn Thomas ♥ @HeartSisters
You know the term “hedging your bets”? Basically, it’s defined by Oxford as “doing something to protect yourself against future problems.” It turns out that when doctors are not 100 per cent sure of the medical diagnosis they are about to share with a patient, researchers who study “diagnostic uncertainty” suggest that these docs tend to start hedging.
In the 2023 medical textbook A Pragmatic Agenda for Healthcare: Australian researchers Drs. Maria Dahm and Carmel Crock wrote about this phenomenon in Chapter 14, sub-titled “A Closer Look at Hedges”.
The chapter explains why healthcare professionals communicate the way they do when they present uncertain diagnostic opinions – by using less forceful/less confident hedging words like maybe, perhaps, might be. . . or actions as described by the Australians like this(1):
“Our study results showed that in interactions linked to diagnostic error, clinicians drew more heavily on evidence and expressed uncertainty indirectly through hesitations, false starts and lengthy evidence-heavy introductory phrases.
“This suggests that clinicians use evidence in the form of ‘shields’ to signal their unconscious lack of commitment to the diagnosis being conveyed. If these ‘shields’ are not recognized as such, shared understanding of the diagnosis might be at risk.”
Hedging during a doctor-patient conversation is a way of cushioning a strong direct answer or opinion – especially if physicians feel hesitant about communicating a diagnosis that may or may not be correct (see what I just did there in that example of a hedging statement?)
I’m fascinated by this topic – and by the overall topic of doctor-patient communication in general, which in some healthcare conversations results in mixed messages, medical jargon gobbledygook, and doctors who don’t recognize how confused their often overwhelmed patients are.
Here’s a real life example from a few years ago of that patient confusion: an elegant older woman sat in the centre front row of the audience at one of my Heart-Smart Women presentations. I remember her clearly to this day: not a hair out of place, her tailored powder blue suit, her gorgeous Italian purse – plus the way she carefully took notes in a little yellow journal throughout. During the Q&A at the end of my 90-minute presentation, she raised one perfectly manicured hand to ask me this question:
“Carolyn, my doctor says I have a ‘heart rhythm problem’. What does that mean?”
What I really wanted to say at that moment was: “Oh, honey. . . you left your doctor’s office without understanding your own diagnosis?!”
The older woman in the powder blue suit actually reminded me of my late mother (except for the tailored suit, the perfect hair, the Italian purse and the manicure).
As my mother’s dementia symptoms slowly evolved, (and before we realized that one of her five grown kids would have to accompany her from now on at every medical appointment) she could rarely answer our questions about those doctor visits (what did the doctor say? did you make a follow-up appointment? what’s this new pill for?) She would never dream of wasting her busy doctor’s time by interrupting to clarify anything she didn’t understand. We now suspect that she was likely nodding and smiling while her doctor was explaining – as if she understood every word.
Dr. Jerome Groopman is a Harvard professor, medical researcher and author of the landmark book, How Doctors Think (which, by the way, should be required reading for all med school students). He writes that, paradoxically, openly addressing diagnostic uncertainty with a patient may actually enhance a physician’s effectiveness, adding:
“It can demonstrate the physician’s honesty, willingness to be more engaged with patients, commitment to the reality of the situation rather than resorting to half-truths, evasion and even lies. And it makes it easier for the doctor to change course or keep trying if the first strategy fails. Uncertainty is sometimes essential for success.”
That last line rings true for me, because admitting “I don’t know” is NOT the same as saying “I don’t care.”
I’d much rather hear a physician say “I’m not sure” than to experience the quick unwarranted certainty of the Emergency doctor who confidently misdiagnosed me with acid reflux (despite my textbook cardiac symptoms of central chest pain, nausea, sweating and pain down my left arm) before I was sent home in mid-heart attack, feeling embarrassed and humiliated for making a fuss over “nothing”.
And as Dr. Dahm reminds her colleagues:
“Not communicating uncertainty can create risks, result in patient harm and, in extreme cases, even contribute to preventable deaths. This happens when patients interpret a tentative diagnosis as a final diagnosis, or are unaware of any uncertainty at all because their doctor didn’t disclose it to them.”
Meanwhile, it’s ultimately our job to speak up for ourselves whenever we have questions or concerns about a diagnosis we’ve just heard. Your doctor – like the doctor of that woman in the powder blue suit – is not a mind reader. Dr. Groopman recommends in his book these three questions we could ask the doctor if we’re feeling confused about a diagnosis:
- “What else could it be?” He warns that the cognitive mistakes that account for most misdiagnoses are not recognized by physicians; they largely reside below the level of conscious thinking. When you ask simply: “What else could it be?”, you help bring closer to the surface the reality of uncertainty in medicine.
- “Is there anything that doesn’t fit?” Dr. Groopman believes that this follow-up should further prompt the physician to pause and let his/her mind roam more broadly.
- “Is it possible I have more than one problem?” He adds that posing this question is another safeguard against one of the most common cognitive traps that physicians can fall into: search satisfaction. It should trigger the doctor to cast a wider net, to begin asking questions that have not yet been posed, or to order more tests that might not have seemed necessary based on initial impressions.
In short, discussing an important medical diagnosis is no time to be hedging.
Heart Sisters 
I had one cardiologist who called me his “enigma” patient, I guess because no diagnosis ever quite fit, which was okay because it was honest and straightforward.
Contrast that with the hospital cardiologist who confidently asserted I had NOT had a heart attack and everything was fine with my heart. It wasn’t. ( I had had a heart attack, but I assume he didn’t check my chart or labs as troponin levels were in the 800’s at that point.)
Now 2 years later we know it was a heart attack, and fibromuscular dysplasia made many aspects of past history much clearer.
I would rather someone be honest and express uncertainty, hedging a bit, than to go with the easiest diagnosis that might fit.
Of course I really want physicians to actually listen to patients.
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Hello Helen – it seems that expressing uncertainty is not the issue – it’s being uncertain but not expressing that uncertainty, ploughing ahead with (as the Australian research found) medical jargon, awkward pauses, repeatedly citing bits of evidence, etc. – all because the physician is not confident of the diagnosis but is unwilling to admit uncertainty.
That troponin blood level of yours was off the charts! Troponin I (cTnI) is typically undetectable in a healthy person’s blood, and generally unique to heart muscle cell damage due to a heart attack (or a recent Iron Man competition!)
I suspect most of us would gladly accept a medical response something like what my reader Dr. Anne Stohrer tells her own patients in this situation: ““I don’t know, but I will be your partner in trying to figure this out.”
She also added “That’s what I say, and that’s what I want to hear!”
Take care. . .❤️
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Thanks for this important article. I appreciate the primer in how to recognize hedging and what specific questions to ask.
I’m a little old lady with a notebook — have had one for years — and ask plenty of questions, but it’s nice to know the right ones to ask!
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Hi Pat – I too carry a notebook at all times! I write like mad at every lecture or conference presentation – sometimes so fast that I have trouble interpreting my handwriting scrawl afterwards.
I think you have hit upon the perfect strategy – keep asking those questions!
Take care. . . ❤️
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In my experience, I have been more comfortable with a doctor “hedging” just a bit than with one that presents a done deal diagnosis that turns out to be wrong – like your ER doc’s diagnosis of GERD.
Maybe because of my medical background, I am comfortable asking questions that will cut through the hedge.
My current situation: I tripped and fell, fracturing my humerus in a couple places. First orthopedic doc looked at the X-rays and said “it looks like you will need a surgical repair…But I’m a back specialist, I will leave it up to the shoulder specialist.”
Shoulder specialist at the hospital said no surgery, a sling and rehab.
Four days later, go to the Orthopedic Clinic for a follow up. That Ortho doc said “Let me talk to the clinic shoulder specialist” – who said definitely surgery.
After I notify my family, 3 hours later, he calls me back and says the Shoulder Guru of Gurus at another clinic said “No surgery, watch and see how it heals and we can always do surgery later if needed.”
Do we need to take a vote? What is going on?
The truth I found out by questioning the doctor was the fracture was displaced, but only mildly. Borderline to qualify for surgery. That coupled with my high risk as a surgical candidate was making the decision a tough call.
Could someone have just said that in the beginning??
So here I am in rehab with broken bones moving around in a sling, going for another X-ray on Wednesday.
Thanks for a good Sunday read and a place to vent a little bit.
Blessings.
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Oh, Jill! I’m so sorry about your fall and associated painful injuries! That sounds so awful. I was thinking while reading about your circuitous path to arrive at a treatment plan: Thank goodness she DOES have a medical background!
The rest of us would have been weeping in frustration by the time we got through all those EXPERTS (I lost track after FIVE!) – each with dueling expert opinions! (Also, thank goodness that, despite your injuries, your keyboard fingers are still able to leave comments here!!)
Quite a wide chasm between “definitely need surgery” and “NO surgery!” Yoiks!
I sure hope your recuperation is uneventful and swift, and that you’re getting lots of practical help just getting yourself around each day in that sling.
Take good care – and good luck in rehab! ❤️
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Another great post Carolyn! And yes, I have had hedging conversations with a doctor. In this case, it was our pediatrician.
My younger son was 3 (he turns 36 on Tuesday!) and had been sick all that year — bronchitis and pneumonia, both twice, and all sorts of respiratory ailments — with many trips to the pediatric office.
Each time I brought him in, the doctor (who was a very sweet and caring man and I really did like him) would say something cautious about him having an “asthmatic response.” He prescribed the right medications, but hedged to make a clear diagnosis, leaving me worrying about what could be wrong.
In September of that year my son couldn’t breathe and I brought him in again. This time we saw a new doctor in the practice who happened to have asthma herself. She took one look at him and said, “He needs to be in the hospital right away — and let’s be clear — he has asthma.”
I was like, THANK YOU!!! Now we know what it is and how best to treat it. And we did, for years — 3 nebulizer treatments a day, plus allergy shots later on. His asthma was pretty severe. He ended up in the hospital again the next month on his 4th birthday, and every year around this time he still has respiratory issues.
Your post made me remember all that, and also made me think of the article I just read yesterday online that made me furious — about a family whose child died because every time they took him in to the ER or the doctor’s office they were told that the child would be fine and the real problem was that the mother was just experiencing too much anxiety.
The correct tests that would have pinpointed what was really wrong were never done. She kept bringing him in, trusting them and believing they were right and that she must be making things worse when she knew her child was having some serious problems.
By the time they took her seriously, it was too late. More than just hedging, she was outright gaslighted and disrespected with a horrible outcome. Parents know their children best and doctors should take all of their observations seriously.
Even though our pediatrician hedged, at least he did take us seriously, examined my son thoroughly, and prescribed the right medications. And seeing the other doctor came at just the right time. Getting a second opinion can be crucial. Hedging can have devastating consequences.
God bless! ~~ Meghan
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Good grief, Meghan – what a horrible experience that must have been watching your little 3-year old so sick! (My grandson Zack is that age, and we would all be out of our minds if we were watching him suffer like that).
An “asthmatic response”?! That’s doctor-speak to differentiate early vs late symptoms. Docs call it “early asthmatic response” when symptoms occur within minutes. That new doctor knew she was not looking at just a benign “asthmatic response”.
And how incredibly fortunate your son was that the new doctor in their practice happened to be there when you most needed immediate direction and appropriate advice. Your example illustrates how even when doctors order the right tests and prescribe the right meds, the WAY they speak and behave can come across as unsure and vague – NOT what a parent needs with a sick child who cannot breathe, no matter how “nice” a doctor is.
My friends who have lived through childhood asthma themselves have a saying: “When you can’t breathe, nothing else matters…”
I wonder how often that tragic story of a parent being told her child was “fine” and she was just being “anxious” happens. That poor family… 😦
Take care . . .❤️
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