Embracing uncertainty: could there be a blueprint from covid-19?

The global impact of covid-19 has been overwhelming and without pause, accelerating at lightning speed. One thing spreading faster than the virus itself is the avalanche of news emerging at frenetic pace. With it, unbounded uncertainty across all domains and from multiple sources: professional and personal; emotional and financial. The combination of rapid proliferation, urgency, and uncertainty makes efforts to control the outbreak particularly difficult. We have rapidly moved across a graded series of responses designed for emerging pandemic viruses and are now close to the very stringent end of the spectrum with lockdowns in place for hundreds of millions of people around the world. [1]

Covid-19’s trajectory is defined by uncertainty: estimates of severity suffer from an uncertain denominator making true mortality figures hard to quantify; uncertainty abounds in individuals’ reactions; and uncertainty is rife with regard to capacity estimates and sustainability of interventions. There are questions regarding the extrapolability of emerging data from elsewhere, whether the advice and equipment used to protect healthcare workers is sufficient, and of course a multitude of questions relating to what is going to happen to loved ones and our nations. In short, uncertainty is everywhere.

The uncertainty embodied by covid-19 appears to be sparing no one. It is indiscriminate to gender, race, ethnicity, and sociodemographic standing. While it has shown a propensity for higher morbidity and mortality in older and more vulnerable populations, the uncertainty rife with the pandemic transgresses age. Our natural discomfort with uncertainty is a legacy of our survival instincts—we are more comfortable with what is familiar and certain, than the unknown, which could be dangerous. Embracing uncertainty is counter to our evolutionary instincts. For centuries, humans have attempted to outsmart uncertainty, optimistically assuming that increases in knowledge would accompany increases in certainty. Nowhere has this fallacy been more true than in medicine, where the quest to eliminate uncertainty in clinical decision-making has become central to biomedical research over the past 50 years, driving the emergence of evidence-based medicine, precision medicine, and more recently, biomedical artificial intelligence. [2] The reality, however, is that although advances in research will continue to improve accuracy of information available for decision-making, uncertainty in medicine—indeed uncertainty in all domains—will always be rife. [3] While no one would have wanted a global catastrophe to catalyze an urgent need to develop ways to embrace uncertainty, perhaps a silver lining from the covid-19 pandemic can be a blueprint of strategies to help us tolerate, learn from, and practice in a new frontier of ever-expanding uncertainty.

The heterogenous approach of combat within countries has demonstrated differing reactions—no “right” course yet charted—with scientists utilizing statistical modelling to try and predict the virus’s course and then suggest action. Responses have frequently seen sudden and dramatic changes in approach, often overnight. For many weeks, the U.K government’s response to covid-19 was to focus on containment, involving identification of people infected with SARS-Cov-2, contact tracing, and isolation of people with proven exposure. Largely business as usual, with the main challenge for many being in the pursuit of toilet paper. Out of sync with the rest of Europe, the government attempted to calm unease by citing scientific wisdom that allowing 60% or more of the population to recover from the infection and approach “herd immunity” would be a strategy that would pay future dividends. [4] Uncertainty abounded, however, not helped by the social media frenzy that keeps people well informed (albeit not always accurately, and sometimes sensationalised for dramatic effect) on alternate efforts and approaches.

Some of the uncertainty thrown in for leaders to consider comes from the publics assumed reactions, with behavioural scientists attempting to guide governments as to public response. This is, however, hard to predict—never before have we been tested with the threat of a highly contagious, novel, infectious disease sweeping the world at a time when global travel is commonplace. As has been demonstrated by notable Nobel Laureates—humans do not behave rationally; with emotion often overpowering cognition. To some degree, what helps propagate uncertainty is lack of clarity and vagueness in strategy. People crave clear guidance which imbues a sense of certainty and with-it apparent security. We do well with the premise of certainty. Unfortunately, it is too often an illusion.

So, how do we embrace uncertainty? The critical first step is to acknowledge its presence and acknowledge the uncertainties we have no control over. [5] Identify knowable unknowns and minimize unnecessary uncertainty—the reassurance and clarity that can come from this distinction is not to be underestimated. Pay attention to your reaction to uncertainty—we have control over how we respond. Most stress comes directly from the way we think and respond, with emotion often amplifying fear and anxiety. By reflecting on the emotions and thoughts uncertainty triggers within us, we can begin to respond mindfully and choose more functional rather than dysfunctional ways to deal with uncertainty—our reaction to uncertainty is modifiable.  Talking openly about uncertainty helps normalize the experience of uncertainty for others, modelling that it is “safe” and necessary to express uncertainty and set a new culture that embraces it. [5] Celebrate uncertainty—it drives curiosity, a fundamental motivator for learning and expanding frontiers.

Communicating uncertainty is challenging, but perhaps this new era can help catalyze more open discussion of uncertainty, proactively including a role for uncertainty in management plans. In many respects, the primary communication task of healthcare professionals has always been the management of uncertainty, yet the culture of medicine has been reluctant to acknowledge this reality. [3] It has been suggested that appropriate expressions of uncertainty can lead to stronger physician-patient relationships, creating trust instead of unnecessary anxiety. [2] We must challenge our cultural and educational systems set up to prioritize and reward certainty, and promote a shift in our perception of uncertainty as negative. 

Critical, of course, is managing channels of incoming uncertainty—a deluge is unhelpful, increasing the noise from which to pick the signal. Focus on relational connections. The technology era creates a plethora of opportunities for remote interactions. Inherent to human need is social community. Virtual connections and open sharing of uncertainties can, and should, be nurtured throughout our medically-induced isolation. Perhaps social media can help manage, rather than spread, the epidemic of uncertainty.

There is still much uncertainty ahead. While experience in China and South Korea has shown that suppression is possible in the short-term, it remains to be seen whether it is possible long-term. There is much uncertainty in the future evolution of the virus, particularly with regard to development of immunity and while the research community works at breakneck and unparalleled speed to devise a vaccine, antibody tests, and an array of effective treatments, we remain in the unknown period of discovery. Although the approach to prioritize and save lives at all costs is beyond question, it will undoubtedly leave in its wake a raft of economic and social costs and repercussions that will likely extend covid-19-associated uncertainties well into this decade.

It is heartening to see the world unite over a common, albeit invisible, enemy. Uncertainty has long been an unwelcome guest. Perhaps in defeating covid-19, we can also eliminate the toxic fear and anxiety that has for too long been fueled by our unhealthy reaction to uncertainty.

Arabella L Simpkin is an assistant professor in medicine at Harvard Medical School. She is the associate director of the Center for Educational Innovation and Scholarship at Massachusetts General Hospital and is currently completing a DPhil in Pharmacology at the University of Oxford looking at uncertainty and the impact it has on burnout in healthcare professionals.

Twitter handle@greyscalespaces

Competing interests: None declared


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