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Comment & Response
July 19, 2021

Uncertainty in Medicine—Reply

Author Affiliations
  • 1Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
  • 2Veterans Affairs Maryland Healthcare System, Baltimore
  • 3Memorial Sloan Kettering Cancer Center, New York, New York
JAMA Intern Med. 2021;181(10):1418. doi:10.1001/jamainternmed.2021.3711

In Reply We appreciate the thoughtful comments by Chaitoff and Patel and Goodman in response to our article.1 They address critical issues in using probability to guide testing and treatment.

Chaitoff emphasizes the role of uncertainty in medicine. A core principle of probability is that uncertainty exists and often is the dominant reality in clinical medicine. Therefore, we should frame medical decisions in terms of chance and uncertainty.2 We thoroughly agree that the uncertainty inherent in medicine requires humility. We believe the consistent overestimation of disease we observed1 needs to be addressed with approaches such as recalibration.3 However, we think the best action for any single patient is rarely certain and patient preferences are essential. Variation in care based on patients and their decisions is optimal, while the widely observed physician-specific variation is problematic. Chaitoff suggests that embracing uncertainty represents a rejection of evidence-based medicine; we would argue that instead it signifies the highest order of its use. More shared decision-making, using the best available evidence as a tool, could better engage patients and limit overuse.4

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