Uncertainty In Medicine
Season
1
Episode
2
|
Apr 10, 2025
Looking with Uncertainty with Alexa Miller
Step inside Alexa Miller’s classroom, where paintings become portals and doctors learn to see like patients. In this episode, Alexa leads a powerful exercise called the “image circle,” where clinicians reflect on their own experiences of medical uncertainty and choose artworks that speak to those moments. What follows is anything but abstract—through close looking and deep conversation, participants begin to feel what it’s like to sit on the other side of the exam table. Alexa, a trailblazer at the crossroads of art and medicine, shares frameworks for understanding uncertainty and introduces her BOLD framework for navigating uncertainty in healthcare.
0:00/1:34
Illustration by Eleni Debo
Uncertainty In Medicine
Season
1
Episode
2
|
Apr 10, 2025
Looking with Uncertainty with Alexa Miller
Step inside Alexa Miller’s classroom, where paintings become portals and doctors learn to see like patients. In this episode, Alexa leads a powerful exercise called the “image circle,” where clinicians reflect on their own experiences of medical uncertainty and choose artworks that speak to those moments. What follows is anything but abstract—through close looking and deep conversation, participants begin to feel what it’s like to sit on the other side of the exam table. Alexa, a trailblazer at the crossroads of art and medicine, shares frameworks for understanding uncertainty and introduces her BOLD framework for navigating uncertainty in healthcare.
0:00/1:34
Illustration by Eleni Debo
Uncertainty In Medicine
Season
1
Episode
2
|
4/10/25
Looking with Uncertainty with Alexa Miller
Step inside Alexa Miller’s classroom, where paintings become portals and doctors learn to see like patients. In this episode, Alexa leads a powerful exercise called the “image circle,” where clinicians reflect on their own experiences of medical uncertainty and choose artworks that speak to those moments. What follows is anything but abstract—through close looking and deep conversation, participants begin to feel what it’s like to sit on the other side of the exam table. Alexa, a trailblazer at the crossroads of art and medicine, shares frameworks for understanding uncertainty and introduces her BOLD framework for navigating uncertainty in healthcare.
0:00/1:34
Illustration by Eleni Debo
About Our Guest
A visual artist by training, Facilitator and Health Humanities teacher Alexa Miller has taught medical students, faculty and teams for over twenty years. An original co-creator of Harvard Medical School’s Training the Eye program, Miller was the first non-MD to hold a Fellowship with the Society to Improve Diagnosis in Medicine, the first Teaching Artist to hold a keynote seminar at the Howard Hughes Medical Institute, and the owner of the first company to train doctors in the Visual Thinking Strategies facilitation methodology for arts engagement. Alexa grew up in an academic family believing that firsts and credentials were to be idolized, though she now laughs to tears at that and focuses on bringing what actually matters–the work of how we see, communicate, and care–to academic communities. Alexa lives, parents, and makes candles outside of New Haven, CT, where she is unable to leave during the month of May because the gardening is just too spectacular. Alexa believes that the art of doctoring is a critical piece of our best possible future, and teaches humanities in the Clinical Arts and Sciences program at Quinnipiac’s Netter School of Medicine.
About The Show
The Nocturnists is an award-winning medical storytelling podcast, hosted by physician Emily Silverman. We feature personal stories from frontline clinicians, conversations with healthcare-related authors, and art-makers. Our mission is to humanize healthcare and foster joy, wonder, and curiosity among clinicians and patients alike.
resources
Credits
About Our Guest
A visual artist by training, Facilitator and Health Humanities teacher Alexa Miller has taught medical students, faculty and teams for over twenty years. An original co-creator of Harvard Medical School’s Training the Eye program, Miller was the first non-MD to hold a Fellowship with the Society to Improve Diagnosis in Medicine, the first Teaching Artist to hold a keynote seminar at the Howard Hughes Medical Institute, and the owner of the first company to train doctors in the Visual Thinking Strategies facilitation methodology for arts engagement. Alexa grew up in an academic family believing that firsts and credentials were to be idolized, though she now laughs to tears at that and focuses on bringing what actually matters–the work of how we see, communicate, and care–to academic communities. Alexa lives, parents, and makes candles outside of New Haven, CT, where she is unable to leave during the month of May because the gardening is just too spectacular. Alexa believes that the art of doctoring is a critical piece of our best possible future, and teaches humanities in the Clinical Arts and Sciences program at Quinnipiac’s Netter School of Medicine.
About The Show
The Nocturnists is an award-winning medical storytelling podcast, hosted by physician Emily Silverman. We feature personal stories from frontline clinicians, conversations with healthcare-related authors, and art-makers. Our mission is to humanize healthcare and foster joy, wonder, and curiosity among clinicians and patients alike.
resources
Credits
About Our Guest
A visual artist by training, Facilitator and Health Humanities teacher Alexa Miller has taught medical students, faculty and teams for over twenty years. An original co-creator of Harvard Medical School’s Training the Eye program, Miller was the first non-MD to hold a Fellowship with the Society to Improve Diagnosis in Medicine, the first Teaching Artist to hold a keynote seminar at the Howard Hughes Medical Institute, and the owner of the first company to train doctors in the Visual Thinking Strategies facilitation methodology for arts engagement. Alexa grew up in an academic family believing that firsts and credentials were to be idolized, though she now laughs to tears at that and focuses on bringing what actually matters–the work of how we see, communicate, and care–to academic communities. Alexa lives, parents, and makes candles outside of New Haven, CT, where she is unable to leave during the month of May because the gardening is just too spectacular. Alexa believes that the art of doctoring is a critical piece of our best possible future, and teaches humanities in the Clinical Arts and Sciences program at Quinnipiac’s Netter School of Medicine.
About The Show
The Nocturnists is an award-winning medical storytelling podcast, hosted by physician Emily Silverman. We feature personal stories from frontline clinicians, conversations with healthcare-related authors, and art-makers. Our mission is to humanize healthcare and foster joy, wonder, and curiosity among clinicians and patients alike.
resources
Credits
The Uncertainty in Medicine series is generously funded by the ABIM Foundation, the Josiah Macy Jr. Foundation, and the Gordon & Betty Moore Foundation. The Nocturnists is supported by The California Medical Association and donations from listeners like you.
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Alexa Miller
Welcome. It is so great to see you guys. What we're going to do today is look closely at some works of art that were selected by a group of medical students I was recently working with.
Emily Silverman
This is The Nocturnists: Uncertainty in Medicine. Today we're spending some time with uncertainty correspondent, Alexa Miller.
Alexa Miller
So this is one of my favorite exercises. It's called an image circle...
Emily Silverman
Alexa has been working for over 20 years as an educator at the intersection of diagnosis, visual art, and uncertainty competence in medicine.
Alexa Miller
...where students first write about the experience of uncertainty as a patient, and then they select an image to speak to what they most want others to know about patient uncertainty.
Emily Silverman
We recently got to sit down as a team and get a taste of one of Alexa's classes.
Alexa Miller
And then we talked about what is actually visible in the works of art that speaks to those pearls of wisdom.
Emily Silverman
Alexa shared a few of the images that her students chose to share with us. We'll hear more from Alexa in a minute. But first step inside Alexa's classroom.
Alexa Miller
There's a couple I thought you guys in particular would like.
Sam
Yeah the first one drew me as the one I was drawn to. yeah.
Emily Silverman
This is Sam, producer and editor at The Nocturnists. Spoiler, the painting is The Lovers II by Renee Magritte, but Alexa didn't tell us that. She just asked Sam to describe it.
Sam
So it is two figures, seemingly a man and a woman, based on their clothing, which is the man is wearing suit, the woman is wearing what looks to be a sleeveless dress, and they're kissing. But what's interesting is they both have what looked to be bed sheets wrapped around their heads so you can't actually see the features of their face, but they're still embracing and still kissing. They're in sort of what looks like a domestic room with a red wall on one side, but the background kind of looks like a, like a cloudy sky, or just like an abstract, non interior space. So it's, it's sort of abstract or surreal. There's something sinister, or maybe like dystopic sense.
Alexa Miller
Yeah. Awesome so you're pointing out the really sort of generalized...
Emily Silverman
When Alexa paraphrases what you just said you can tell she's been doing this for a long time. She makes you sound like a creative genius, and then pushes you to dig further. Why does what you see lead you to say that? How is your interpretation related to your observation?
Sam
Like I think commonly when you see people with sheets over their head they've either been kidnapped or they're being interrogated like it's it's that kind of thing where, where you're seeing control being exerted over someone.
Molly Rose-Williams
Yeah I think one of the things when I look at this...
Emily Silverman
This is Molly, Head of Story Development...
Molly Rose-Williams
...begs the question of what's happening outside the frame, because there's something about this painting also that almost feels as if it zoomed in on the figures. We only see them from their shoulders up.
Emily Silverman
This is an exercise Alexa has done with medical students for years now. And once you get into it, it's not hard to see why. The type of close observation it encourages is the exact same thing clinicians do all day long - paying attention to detail and grounding your interpretation in the evidence in front of you. Over and over again. But it goes a step further. It explicitly introduces the possibility of multiple interpretations.
Alexa Miller
Wonderful. Thank you both so much.
Emily Silverman
We got pretty into it. Go ahead, Emily. Well I was just gonna say kissing is such a like sensory and tactile thing. It's about...once we'd had a chance to each share our own interpretation of the artwork, Alexa shared with us what the student who chose the image had been thinking when they chose it. Why for them, it represented patient uncertainty.
Alexa Miller
So what this student put a finger on was the idea of the blindness of trust that patients put into their doctors and into the healthcare system.
Emily Silverman
Once we did one image, we did another.
Alexa Miller
That sort of pregnant uncertainty that a patient has just before making a medical decision...
Emily Silverman
and another...
Alexa Miller
saying that just one person is holding the light in this...
Molly Rose-Williams
Whole point on the figures...
Emily Silverman
It looks like nighttime...
Sam
...the stars stand out to me...
Alexa Miller
...that should be the patient as the leader or the decision maker.
Emily Silverman
We could have done this for a long time.
Alexa Miller
Use the phrase protectively and reverently holding a light close to the chest.
Emily Silverman
Last week, we introduced Alexa her personal journey and some key definitions of Uncertainty in Medicine. Today, we take a deeper dive into what Alexa has discovered over the years and how reimagining our relationship with uncertainty could transform healthcare for the better. To start, she gave us a little historical context.
Alexa Miller
There was like a golden age of diagnosis that has passed. That was in the age when clinical times were like half an hour to an hour, and the system itself was more run by MDs and less by MBAs.
Emily Silverman
This was a time commonly talked about as starting in the late 19th century, when some major advances in microbiology brought western medicine leaps and bounds in terms of being able to functionally diagnose and treat a whole range of infectious diseases. The other thing that characterized that period of time, though, Alexa says, was the amount of time and emphasis placed on the patient, clinician relationship. That all changed in the 1980s with the rise of MRI, the electronic health record and other technologies. Big business and insurance increasingly began dictating what happened in the exam room, and clinicians started to spend less and less time with their patients.
Alexa Miller
And interestingly, that is when a lot of the visual arts and art museum humanities programs in medical education took a big jump. It was right around the time when imaging technology started to explode and medical teachers started to notice a decreased confidence of their residents and their students on the wards in terms of just physical exam and having the confidence to just look at patients.
Emily Silverman
That trend fueled the program that Alexa got her start in -- a humanities program she designed for medical students at Harvard that she called training the eye.
Alexa Miller
That was what the faculty who founded that program talked about, like, we need to do something because students aren't looking at patients anymore. And let's look to the visual arts.
Emily Silverman
in training the eye, Alexa said the primary learning objective was to make careful observation a habit for students, and she taught the class for many years. But over time, she started realizing that having students engage closely with art wasn't just teaching about observation, it was also touching on something no one in the medical world seemed to be talking about. Uncertainty.
Alexa Miller
I kept hearing these conversations about uncertainty and the uncertainty in the art being authentic, and the uncertainty in the clinic being very stressful, and the students wanting more conversation and capacity around that. I was really listening to what they were asking for and I was also very personally connecting it to my sister's misdiagnosis. And, you know, people coming to conclusions way too early in uncertainty. And so what I began aspiring for the students to do was what I now call look with uncertainty. To not react to uncertainty or get defensive in it or sort of treat it like a place of shame, but rather to look with it. Look with it like you would look at a work of art with a friend and lean into it as this space to drive learning, drive what we call forcing strategies, or looking at something in a different way. All the actions associated with curiosity and learning and co-creation of health, rather than a place to shut down and, you know, feel the stress of not knowing when you're the expert, which is also very stressful. But it's that mismanagement of uncertainty in those moments that is a root cause of so many errors.
Emily Silverman
Alexa was inspired. She not only started explicitly teaching about uncertainty and uncertainty response in her classes, using art as a framework, she also started reading as much as she possibly could about other people's research on the topic. And the deeper she got, the more she was convinced. Uncertainty was it. How we respond to it, how we communicate about it. It was like this holy grail of potential in medicine.
Alexa Miller
The more I learn about the research, you know, patient safety experts who certainly do not agree on everything really do agree across the board that that critical zone of uncertainty and communication in uncertainty is like this tipping point place of things either going very well in healthcare or going wrong.
Emily Silverman
I think we probably all have stories about how communication and uncertainty has gone wrong, but when it goes well, it can be really, really striking. Like when you encounter a doctor who isn't moved to repeat the same old testing again and again, but instead sits down with you and asks new questions. And then figure something out based on the story that you told them. Alexa found that one of the best ways to teach this was using art to explore uncertainty and uncertainty response.
Alexa Miller
The uncertainty is just as authentic it's just as real, but it's very low risk. Nobody's life is on the line. No resources are on the line other than the time that you're taking to learn and works of art, also, put forth an expectation that there's many different things we could potentially see, and so it's a wonderful context to develop new skills and have actually have success in some of these forcing strategies, such as shifting perspective or looking at something in a new way or looking a little bit longer and discovering a new detail after maybe 10 minutes.
Emily Silverman
Alexa started developing a curriculum that integrated her approach of teaching students to look with uncertainty at artwork with theory and concepts that she pulled from the body of the academic research out there. A lot of the theory came from Uncertainty Scholar and Palliative Care Physician Paul Hahn, who has been a pioneer in delineating different types of clinical uncertainty.
Alexa Miller
Paul Hahn has an article on varieties of uncertainty in healthcare, and that one really demystified for me a way of thinking about it, which is to break it down into like three chunks. So, is the uncertainty arising from probability? Like, okay, there's a 20% probability of benefit from this treatment. That's a probability uncertainty. Is it arising from ambiguity? That's when, like, you really don't know. Like, maybe we have a 10% to a 30% probability of benefit from the treatment, but the experts also totally disagree about the different kinds of treatments and their benefits, and we just don't have enough scientific evidence. So that's a different kind of uncertainty. And then lastly, he talks about complexity. So, like there's a 20% probability of benefit from this treatment, but there's also comorbidities, and there's, you know, a bunch of other factors making the situation complex.
Emily Silverman
To these basic frameworks, Alexa also added a fourth bucket she calls counterfeit uncertainty. Or uncertainty that's manufactured by the system.
Alexa Miller
A big one, for example, is decreased clinical times. If clinical times are so short that the doctor does not have time to do a physical exam, there's undue uncertainty as a result of of that time. The
Emily Silverman
The key in all this is giving clinicians more tools to effectively respond to uncertainty. And different types of uncertainty require different types of responses. For probability uncertainty, how do we apply probability clouds to individual people? For ambiguity, what do we know and how do we move forward from there. For complexity, how do we do our best and stay agile as things change. And for counterfeit, when do we adapt to the dysfunction of the system and when do we push back? In her classroom, Alexa invites us to consider these questions, not just through the eyes of clinicians, but through the eyes of patients. And from there, she introduces BOLD -- a simple yet powerful framework for how the most effective clinicians respond to uncertainty.
Alexa Miller
It's a really simple model for clinicians in moments of uncertainty to counteract some of these forces that can lead to harm. So it just begins with actually believing patients believing that their story is legitimate. I mean, so many cases of harm don't even progress beyond believing the patient. Like you know, you look at something like endometriosis that impacts almost 10% of women, and right now, the diagnostic interval like the time it takes to get diagnosed in endometriosis is like I thought it was 4 years, and I thought that was bad, and I just learned the other day in a research study, it's 6 to 11. And it's it's so painful, and so those delays are a result of women not being believed. Simply believing the patient is, is a first step, right. Then the second being observe, to look really unflinchingly at what's there, to look holistically and to look through and with the perspectives of others. I have another little cadence that I teach about kind of related to that, which is to look fresh, look with, and then look for. And that actually comes from observing some really masterful radiologists over the years, Dr. Kit Schaefer in Boston and Dr. Vickie Feldstein at UCSF. These are radiologists who I've heard sort of teach the same cadence to their learner, which is like, before you even go to the chart and know what you're supposed to be looking for, just look at the radiograph. Just look at the ultrasound to let it hit you. Let what's weird about it or notable about it hit you. So look fresh. Then, go to the chart, find out what you're looking for. Look for step two. And then, ideally, look get a colleague and look at it again with another perspective to live with. But these simple practices that are not actually that costly, except for time, can prevent a lot of delays and missed findings.
Emily Silverman
B, believe, O, observe, which is happening less and less in corporatized healthcare and L for location.
Alexa Miller
So location is in a few different domains. It starts with actually being able to situate yourself in time and place and knowing your strengths and knowing your challenges, knowing what you do know, and also knowing what you don't. And from there, being able to locate in the patient the root cause of their concern, really sort of touching the pain point, if you will, as well as being connected to their goals and aspirations at all times. And then the D is deciding together towards agency and wholeness. So that's like a shared decision making approach, really, but in the service of patient goals.
Emily Silverman
Thanks for listening to The Nocturnists Uncertainty in Medicine. Our core uncertainty team includes me, Emily Silverman, the Nocturnist head of story development, Molly Rose Williams, producer and editor, Sam Osborn and our uncertainty correspondent, Alexa Miller of arts practica, our student producers are Clare Nimura and Selin Everett. Special thanks to Maggie Jackson and Paul Hahn. Our executive producer is Ali Block. Our program director is Ashley Pettit. Our original theme music was composed by Asche & Spencer, and additional music came from Blue Dot sessions. Artwork for Uncertainty in Medicine was created by Eleni Debo, who is represented by folio illustration and animation agency. The nocturnist Uncertainty in Medicine was made possible by generous support from the ABIM Foundation, the Gordon and Betty Moore Foundation and the Josiah Macy Jr Foundation. The nocturnist title sponsor is the California Medical Association, a physician led organization that works to keep the doctor patient relationship at the heart of medicine. To learn more, visit cmadocs.org, the nocturnist is also made possible by support from listeners like you. In fact, we recently moved over to substack, which makes it easier than ever to support our work directly. By joining us for a monthly or annual membership, you will become an essential part of our creative community. If you enjoy the show, consider signing up today at the nocturnists.substack.com if you enjoy this episode, please share with a friend or colleague. Post on social media and help others find us by giving us a rating and review in your favorite podcast app. I'm your host. Emily Silverman, see you next week.
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Alexa Miller
Welcome. It is so great to see you guys. What we're going to do today is look closely at some works of art that were selected by a group of medical students I was recently working with.
Emily Silverman
This is The Nocturnists: Uncertainty in Medicine. Today we're spending some time with uncertainty correspondent, Alexa Miller.
Alexa Miller
So this is one of my favorite exercises. It's called an image circle...
Emily Silverman
Alexa has been working for over 20 years as an educator at the intersection of diagnosis, visual art, and uncertainty competence in medicine.
Alexa Miller
...where students first write about the experience of uncertainty as a patient, and then they select an image to speak to what they most want others to know about patient uncertainty.
Emily Silverman
We recently got to sit down as a team and get a taste of one of Alexa's classes.
Alexa Miller
And then we talked about what is actually visible in the works of art that speaks to those pearls of wisdom.
Emily Silverman
Alexa shared a few of the images that her students chose to share with us. We'll hear more from Alexa in a minute. But first step inside Alexa's classroom.
Alexa Miller
There's a couple I thought you guys in particular would like.
Sam
Yeah the first one drew me as the one I was drawn to. yeah.
Emily Silverman
This is Sam, producer and editor at The Nocturnists. Spoiler, the painting is The Lovers II by Renee Magritte, but Alexa didn't tell us that. She just asked Sam to describe it.
Sam
So it is two figures, seemingly a man and a woman, based on their clothing, which is the man is wearing suit, the woman is wearing what looks to be a sleeveless dress, and they're kissing. But what's interesting is they both have what looked to be bed sheets wrapped around their heads so you can't actually see the features of their face, but they're still embracing and still kissing. They're in sort of what looks like a domestic room with a red wall on one side, but the background kind of looks like a, like a cloudy sky, or just like an abstract, non interior space. So it's, it's sort of abstract or surreal. There's something sinister, or maybe like dystopic sense.
Alexa Miller
Yeah. Awesome so you're pointing out the really sort of generalized...
Emily Silverman
When Alexa paraphrases what you just said you can tell she's been doing this for a long time. She makes you sound like a creative genius, and then pushes you to dig further. Why does what you see lead you to say that? How is your interpretation related to your observation?
Sam
Like I think commonly when you see people with sheets over their head they've either been kidnapped or they're being interrogated like it's it's that kind of thing where, where you're seeing control being exerted over someone.
Molly Rose-Williams
Yeah I think one of the things when I look at this...
Emily Silverman
This is Molly, Head of Story Development...
Molly Rose-Williams
...begs the question of what's happening outside the frame, because there's something about this painting also that almost feels as if it zoomed in on the figures. We only see them from their shoulders up.
Emily Silverman
This is an exercise Alexa has done with medical students for years now. And once you get into it, it's not hard to see why. The type of close observation it encourages is the exact same thing clinicians do all day long - paying attention to detail and grounding your interpretation in the evidence in front of you. Over and over again. But it goes a step further. It explicitly introduces the possibility of multiple interpretations.
Alexa Miller
Wonderful. Thank you both so much.
Emily Silverman
We got pretty into it. Go ahead, Emily. Well I was just gonna say kissing is such a like sensory and tactile thing. It's about...once we'd had a chance to each share our own interpretation of the artwork, Alexa shared with us what the student who chose the image had been thinking when they chose it. Why for them, it represented patient uncertainty.
Alexa Miller
So what this student put a finger on was the idea of the blindness of trust that patients put into their doctors and into the healthcare system.
Emily Silverman
Once we did one image, we did another.
Alexa Miller
That sort of pregnant uncertainty that a patient has just before making a medical decision...
Emily Silverman
and another...
Alexa Miller
saying that just one person is holding the light in this...
Molly Rose-Williams
Whole point on the figures...
Emily Silverman
It looks like nighttime...
Sam
...the stars stand out to me...
Alexa Miller
...that should be the patient as the leader or the decision maker.
Emily Silverman
We could have done this for a long time.
Alexa Miller
Use the phrase protectively and reverently holding a light close to the chest.
Emily Silverman
Last week, we introduced Alexa her personal journey and some key definitions of Uncertainty in Medicine. Today, we take a deeper dive into what Alexa has discovered over the years and how reimagining our relationship with uncertainty could transform healthcare for the better. To start, she gave us a little historical context.
Alexa Miller
There was like a golden age of diagnosis that has passed. That was in the age when clinical times were like half an hour to an hour, and the system itself was more run by MDs and less by MBAs.
Emily Silverman
This was a time commonly talked about as starting in the late 19th century, when some major advances in microbiology brought western medicine leaps and bounds in terms of being able to functionally diagnose and treat a whole range of infectious diseases. The other thing that characterized that period of time, though, Alexa says, was the amount of time and emphasis placed on the patient, clinician relationship. That all changed in the 1980s with the rise of MRI, the electronic health record and other technologies. Big business and insurance increasingly began dictating what happened in the exam room, and clinicians started to spend less and less time with their patients.
Alexa Miller
And interestingly, that is when a lot of the visual arts and art museum humanities programs in medical education took a big jump. It was right around the time when imaging technology started to explode and medical teachers started to notice a decreased confidence of their residents and their students on the wards in terms of just physical exam and having the confidence to just look at patients.
Emily Silverman
That trend fueled the program that Alexa got her start in -- a humanities program she designed for medical students at Harvard that she called training the eye.
Alexa Miller
That was what the faculty who founded that program talked about, like, we need to do something because students aren't looking at patients anymore. And let's look to the visual arts.
Emily Silverman
in training the eye, Alexa said the primary learning objective was to make careful observation a habit for students, and she taught the class for many years. But over time, she started realizing that having students engage closely with art wasn't just teaching about observation, it was also touching on something no one in the medical world seemed to be talking about. Uncertainty.
Alexa Miller
I kept hearing these conversations about uncertainty and the uncertainty in the art being authentic, and the uncertainty in the clinic being very stressful, and the students wanting more conversation and capacity around that. I was really listening to what they were asking for and I was also very personally connecting it to my sister's misdiagnosis. And, you know, people coming to conclusions way too early in uncertainty. And so what I began aspiring for the students to do was what I now call look with uncertainty. To not react to uncertainty or get defensive in it or sort of treat it like a place of shame, but rather to look with it. Look with it like you would look at a work of art with a friend and lean into it as this space to drive learning, drive what we call forcing strategies, or looking at something in a different way. All the actions associated with curiosity and learning and co-creation of health, rather than a place to shut down and, you know, feel the stress of not knowing when you're the expert, which is also very stressful. But it's that mismanagement of uncertainty in those moments that is a root cause of so many errors.
Emily Silverman
Alexa was inspired. She not only started explicitly teaching about uncertainty and uncertainty response in her classes, using art as a framework, she also started reading as much as she possibly could about other people's research on the topic. And the deeper she got, the more she was convinced. Uncertainty was it. How we respond to it, how we communicate about it. It was like this holy grail of potential in medicine.
Alexa Miller
The more I learn about the research, you know, patient safety experts who certainly do not agree on everything really do agree across the board that that critical zone of uncertainty and communication in uncertainty is like this tipping point place of things either going very well in healthcare or going wrong.
Emily Silverman
I think we probably all have stories about how communication and uncertainty has gone wrong, but when it goes well, it can be really, really striking. Like when you encounter a doctor who isn't moved to repeat the same old testing again and again, but instead sits down with you and asks new questions. And then figure something out based on the story that you told them. Alexa found that one of the best ways to teach this was using art to explore uncertainty and uncertainty response.
Alexa Miller
The uncertainty is just as authentic it's just as real, but it's very low risk. Nobody's life is on the line. No resources are on the line other than the time that you're taking to learn and works of art, also, put forth an expectation that there's many different things we could potentially see, and so it's a wonderful context to develop new skills and have actually have success in some of these forcing strategies, such as shifting perspective or looking at something in a new way or looking a little bit longer and discovering a new detail after maybe 10 minutes.
Emily Silverman
Alexa started developing a curriculum that integrated her approach of teaching students to look with uncertainty at artwork with theory and concepts that she pulled from the body of the academic research out there. A lot of the theory came from Uncertainty Scholar and Palliative Care Physician Paul Hahn, who has been a pioneer in delineating different types of clinical uncertainty.
Alexa Miller
Paul Hahn has an article on varieties of uncertainty in healthcare, and that one really demystified for me a way of thinking about it, which is to break it down into like three chunks. So, is the uncertainty arising from probability? Like, okay, there's a 20% probability of benefit from this treatment. That's a probability uncertainty. Is it arising from ambiguity? That's when, like, you really don't know. Like, maybe we have a 10% to a 30% probability of benefit from the treatment, but the experts also totally disagree about the different kinds of treatments and their benefits, and we just don't have enough scientific evidence. So that's a different kind of uncertainty. And then lastly, he talks about complexity. So, like there's a 20% probability of benefit from this treatment, but there's also comorbidities, and there's, you know, a bunch of other factors making the situation complex.
Emily Silverman
To these basic frameworks, Alexa also added a fourth bucket she calls counterfeit uncertainty. Or uncertainty that's manufactured by the system.
Alexa Miller
A big one, for example, is decreased clinical times. If clinical times are so short that the doctor does not have time to do a physical exam, there's undue uncertainty as a result of of that time. The
Emily Silverman
The key in all this is giving clinicians more tools to effectively respond to uncertainty. And different types of uncertainty require different types of responses. For probability uncertainty, how do we apply probability clouds to individual people? For ambiguity, what do we know and how do we move forward from there. For complexity, how do we do our best and stay agile as things change. And for counterfeit, when do we adapt to the dysfunction of the system and when do we push back? In her classroom, Alexa invites us to consider these questions, not just through the eyes of clinicians, but through the eyes of patients. And from there, she introduces BOLD -- a simple yet powerful framework for how the most effective clinicians respond to uncertainty.
Alexa Miller
It's a really simple model for clinicians in moments of uncertainty to counteract some of these forces that can lead to harm. So it just begins with actually believing patients believing that their story is legitimate. I mean, so many cases of harm don't even progress beyond believing the patient. Like you know, you look at something like endometriosis that impacts almost 10% of women, and right now, the diagnostic interval like the time it takes to get diagnosed in endometriosis is like I thought it was 4 years, and I thought that was bad, and I just learned the other day in a research study, it's 6 to 11. And it's it's so painful, and so those delays are a result of women not being believed. Simply believing the patient is, is a first step, right. Then the second being observe, to look really unflinchingly at what's there, to look holistically and to look through and with the perspectives of others. I have another little cadence that I teach about kind of related to that, which is to look fresh, look with, and then look for. And that actually comes from observing some really masterful radiologists over the years, Dr. Kit Schaefer in Boston and Dr. Vickie Feldstein at UCSF. These are radiologists who I've heard sort of teach the same cadence to their learner, which is like, before you even go to the chart and know what you're supposed to be looking for, just look at the radiograph. Just look at the ultrasound to let it hit you. Let what's weird about it or notable about it hit you. So look fresh. Then, go to the chart, find out what you're looking for. Look for step two. And then, ideally, look get a colleague and look at it again with another perspective to live with. But these simple practices that are not actually that costly, except for time, can prevent a lot of delays and missed findings.
Emily Silverman
B, believe, O, observe, which is happening less and less in corporatized healthcare and L for location.
Alexa Miller
So location is in a few different domains. It starts with actually being able to situate yourself in time and place and knowing your strengths and knowing your challenges, knowing what you do know, and also knowing what you don't. And from there, being able to locate in the patient the root cause of their concern, really sort of touching the pain point, if you will, as well as being connected to their goals and aspirations at all times. And then the D is deciding together towards agency and wholeness. So that's like a shared decision making approach, really, but in the service of patient goals.
Emily Silverman
Thanks for listening to The Nocturnists Uncertainty in Medicine. Our core uncertainty team includes me, Emily Silverman, the Nocturnist head of story development, Molly Rose Williams, producer and editor, Sam Osborn and our uncertainty correspondent, Alexa Miller of arts practica, our student producers are Clare Nimura and Selin Everett. Special thanks to Maggie Jackson and Paul Hahn. Our executive producer is Ali Block. Our program director is Ashley Pettit. Our original theme music was composed by Asche & Spencer, and additional music came from Blue Dot sessions. Artwork for Uncertainty in Medicine was created by Eleni Debo, who is represented by folio illustration and animation agency. The nocturnist Uncertainty in Medicine was made possible by generous support from the ABIM Foundation, the Gordon and Betty Moore Foundation and the Josiah Macy Jr Foundation. The nocturnist title sponsor is the California Medical Association, a physician led organization that works to keep the doctor patient relationship at the heart of medicine. To learn more, visit cmadocs.org, the nocturnist is also made possible by support from listeners like you. In fact, we recently moved over to substack, which makes it easier than ever to support our work directly. By joining us for a monthly or annual membership, you will become an essential part of our creative community. If you enjoy the show, consider signing up today at the nocturnists.substack.com if you enjoy this episode, please share with a friend or colleague. Post on social media and help others find us by giving us a rating and review in your favorite podcast app. I'm your host. Emily Silverman, see you next week.
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Alexa Miller
Welcome. It is so great to see you guys. What we're going to do today is look closely at some works of art that were selected by a group of medical students I was recently working with.
Emily Silverman
This is The Nocturnists: Uncertainty in Medicine. Today we're spending some time with uncertainty correspondent, Alexa Miller.
Alexa Miller
So this is one of my favorite exercises. It's called an image circle...
Emily Silverman
Alexa has been working for over 20 years as an educator at the intersection of diagnosis, visual art, and uncertainty competence in medicine.
Alexa Miller
...where students first write about the experience of uncertainty as a patient, and then they select an image to speak to what they most want others to know about patient uncertainty.
Emily Silverman
We recently got to sit down as a team and get a taste of one of Alexa's classes.
Alexa Miller
And then we talked about what is actually visible in the works of art that speaks to those pearls of wisdom.
Emily Silverman
Alexa shared a few of the images that her students chose to share with us. We'll hear more from Alexa in a minute. But first step inside Alexa's classroom.
Alexa Miller
There's a couple I thought you guys in particular would like.
Sam
Yeah the first one drew me as the one I was drawn to. yeah.
Emily Silverman
This is Sam, producer and editor at The Nocturnists. Spoiler, the painting is The Lovers II by Renee Magritte, but Alexa didn't tell us that. She just asked Sam to describe it.
Sam
So it is two figures, seemingly a man and a woman, based on their clothing, which is the man is wearing suit, the woman is wearing what looks to be a sleeveless dress, and they're kissing. But what's interesting is they both have what looked to be bed sheets wrapped around their heads so you can't actually see the features of their face, but they're still embracing and still kissing. They're in sort of what looks like a domestic room with a red wall on one side, but the background kind of looks like a, like a cloudy sky, or just like an abstract, non interior space. So it's, it's sort of abstract or surreal. There's something sinister, or maybe like dystopic sense.
Alexa Miller
Yeah. Awesome so you're pointing out the really sort of generalized...
Emily Silverman
When Alexa paraphrases what you just said you can tell she's been doing this for a long time. She makes you sound like a creative genius, and then pushes you to dig further. Why does what you see lead you to say that? How is your interpretation related to your observation?
Sam
Like I think commonly when you see people with sheets over their head they've either been kidnapped or they're being interrogated like it's it's that kind of thing where, where you're seeing control being exerted over someone.
Molly Rose-Williams
Yeah I think one of the things when I look at this...
Emily Silverman
This is Molly, Head of Story Development...
Molly Rose-Williams
...begs the question of what's happening outside the frame, because there's something about this painting also that almost feels as if it zoomed in on the figures. We only see them from their shoulders up.
Emily Silverman
This is an exercise Alexa has done with medical students for years now. And once you get into it, it's not hard to see why. The type of close observation it encourages is the exact same thing clinicians do all day long - paying attention to detail and grounding your interpretation in the evidence in front of you. Over and over again. But it goes a step further. It explicitly introduces the possibility of multiple interpretations.
Alexa Miller
Wonderful. Thank you both so much.
Emily Silverman
We got pretty into it. Go ahead, Emily. Well I was just gonna say kissing is such a like sensory and tactile thing. It's about...once we'd had a chance to each share our own interpretation of the artwork, Alexa shared with us what the student who chose the image had been thinking when they chose it. Why for them, it represented patient uncertainty.
Alexa Miller
So what this student put a finger on was the idea of the blindness of trust that patients put into their doctors and into the healthcare system.
Emily Silverman
Once we did one image, we did another.
Alexa Miller
That sort of pregnant uncertainty that a patient has just before making a medical decision...
Emily Silverman
and another...
Alexa Miller
saying that just one person is holding the light in this...
Molly Rose-Williams
Whole point on the figures...
Emily Silverman
It looks like nighttime...
Sam
...the stars stand out to me...
Alexa Miller
...that should be the patient as the leader or the decision maker.
Emily Silverman
We could have done this for a long time.
Alexa Miller
Use the phrase protectively and reverently holding a light close to the chest.
Emily Silverman
Last week, we introduced Alexa her personal journey and some key definitions of Uncertainty in Medicine. Today, we take a deeper dive into what Alexa has discovered over the years and how reimagining our relationship with uncertainty could transform healthcare for the better. To start, she gave us a little historical context.
Alexa Miller
There was like a golden age of diagnosis that has passed. That was in the age when clinical times were like half an hour to an hour, and the system itself was more run by MDs and less by MBAs.
Emily Silverman
This was a time commonly talked about as starting in the late 19th century, when some major advances in microbiology brought western medicine leaps and bounds in terms of being able to functionally diagnose and treat a whole range of infectious diseases. The other thing that characterized that period of time, though, Alexa says, was the amount of time and emphasis placed on the patient, clinician relationship. That all changed in the 1980s with the rise of MRI, the electronic health record and other technologies. Big business and insurance increasingly began dictating what happened in the exam room, and clinicians started to spend less and less time with their patients.
Alexa Miller
And interestingly, that is when a lot of the visual arts and art museum humanities programs in medical education took a big jump. It was right around the time when imaging technology started to explode and medical teachers started to notice a decreased confidence of their residents and their students on the wards in terms of just physical exam and having the confidence to just look at patients.
Emily Silverman
That trend fueled the program that Alexa got her start in -- a humanities program she designed for medical students at Harvard that she called training the eye.
Alexa Miller
That was what the faculty who founded that program talked about, like, we need to do something because students aren't looking at patients anymore. And let's look to the visual arts.
Emily Silverman
in training the eye, Alexa said the primary learning objective was to make careful observation a habit for students, and she taught the class for many years. But over time, she started realizing that having students engage closely with art wasn't just teaching about observation, it was also touching on something no one in the medical world seemed to be talking about. Uncertainty.
Alexa Miller
I kept hearing these conversations about uncertainty and the uncertainty in the art being authentic, and the uncertainty in the clinic being very stressful, and the students wanting more conversation and capacity around that. I was really listening to what they were asking for and I was also very personally connecting it to my sister's misdiagnosis. And, you know, people coming to conclusions way too early in uncertainty. And so what I began aspiring for the students to do was what I now call look with uncertainty. To not react to uncertainty or get defensive in it or sort of treat it like a place of shame, but rather to look with it. Look with it like you would look at a work of art with a friend and lean into it as this space to drive learning, drive what we call forcing strategies, or looking at something in a different way. All the actions associated with curiosity and learning and co-creation of health, rather than a place to shut down and, you know, feel the stress of not knowing when you're the expert, which is also very stressful. But it's that mismanagement of uncertainty in those moments that is a root cause of so many errors.
Emily Silverman
Alexa was inspired. She not only started explicitly teaching about uncertainty and uncertainty response in her classes, using art as a framework, she also started reading as much as she possibly could about other people's research on the topic. And the deeper she got, the more she was convinced. Uncertainty was it. How we respond to it, how we communicate about it. It was like this holy grail of potential in medicine.
Alexa Miller
The more I learn about the research, you know, patient safety experts who certainly do not agree on everything really do agree across the board that that critical zone of uncertainty and communication in uncertainty is like this tipping point place of things either going very well in healthcare or going wrong.
Emily Silverman
I think we probably all have stories about how communication and uncertainty has gone wrong, but when it goes well, it can be really, really striking. Like when you encounter a doctor who isn't moved to repeat the same old testing again and again, but instead sits down with you and asks new questions. And then figure something out based on the story that you told them. Alexa found that one of the best ways to teach this was using art to explore uncertainty and uncertainty response.
Alexa Miller
The uncertainty is just as authentic it's just as real, but it's very low risk. Nobody's life is on the line. No resources are on the line other than the time that you're taking to learn and works of art, also, put forth an expectation that there's many different things we could potentially see, and so it's a wonderful context to develop new skills and have actually have success in some of these forcing strategies, such as shifting perspective or looking at something in a new way or looking a little bit longer and discovering a new detail after maybe 10 minutes.
Emily Silverman
Alexa started developing a curriculum that integrated her approach of teaching students to look with uncertainty at artwork with theory and concepts that she pulled from the body of the academic research out there. A lot of the theory came from Uncertainty Scholar and Palliative Care Physician Paul Hahn, who has been a pioneer in delineating different types of clinical uncertainty.
Alexa Miller
Paul Hahn has an article on varieties of uncertainty in healthcare, and that one really demystified for me a way of thinking about it, which is to break it down into like three chunks. So, is the uncertainty arising from probability? Like, okay, there's a 20% probability of benefit from this treatment. That's a probability uncertainty. Is it arising from ambiguity? That's when, like, you really don't know. Like, maybe we have a 10% to a 30% probability of benefit from the treatment, but the experts also totally disagree about the different kinds of treatments and their benefits, and we just don't have enough scientific evidence. So that's a different kind of uncertainty. And then lastly, he talks about complexity. So, like there's a 20% probability of benefit from this treatment, but there's also comorbidities, and there's, you know, a bunch of other factors making the situation complex.
Emily Silverman
To these basic frameworks, Alexa also added a fourth bucket she calls counterfeit uncertainty. Or uncertainty that's manufactured by the system.
Alexa Miller
A big one, for example, is decreased clinical times. If clinical times are so short that the doctor does not have time to do a physical exam, there's undue uncertainty as a result of of that time. The
Emily Silverman
The key in all this is giving clinicians more tools to effectively respond to uncertainty. And different types of uncertainty require different types of responses. For probability uncertainty, how do we apply probability clouds to individual people? For ambiguity, what do we know and how do we move forward from there. For complexity, how do we do our best and stay agile as things change. And for counterfeit, when do we adapt to the dysfunction of the system and when do we push back? In her classroom, Alexa invites us to consider these questions, not just through the eyes of clinicians, but through the eyes of patients. And from there, she introduces BOLD -- a simple yet powerful framework for how the most effective clinicians respond to uncertainty.
Alexa Miller
It's a really simple model for clinicians in moments of uncertainty to counteract some of these forces that can lead to harm. So it just begins with actually believing patients believing that their story is legitimate. I mean, so many cases of harm don't even progress beyond believing the patient. Like you know, you look at something like endometriosis that impacts almost 10% of women, and right now, the diagnostic interval like the time it takes to get diagnosed in endometriosis is like I thought it was 4 years, and I thought that was bad, and I just learned the other day in a research study, it's 6 to 11. And it's it's so painful, and so those delays are a result of women not being believed. Simply believing the patient is, is a first step, right. Then the second being observe, to look really unflinchingly at what's there, to look holistically and to look through and with the perspectives of others. I have another little cadence that I teach about kind of related to that, which is to look fresh, look with, and then look for. And that actually comes from observing some really masterful radiologists over the years, Dr. Kit Schaefer in Boston and Dr. Vickie Feldstein at UCSF. These are radiologists who I've heard sort of teach the same cadence to their learner, which is like, before you even go to the chart and know what you're supposed to be looking for, just look at the radiograph. Just look at the ultrasound to let it hit you. Let what's weird about it or notable about it hit you. So look fresh. Then, go to the chart, find out what you're looking for. Look for step two. And then, ideally, look get a colleague and look at it again with another perspective to live with. But these simple practices that are not actually that costly, except for time, can prevent a lot of delays and missed findings.
Emily Silverman
B, believe, O, observe, which is happening less and less in corporatized healthcare and L for location.
Alexa Miller
So location is in a few different domains. It starts with actually being able to situate yourself in time and place and knowing your strengths and knowing your challenges, knowing what you do know, and also knowing what you don't. And from there, being able to locate in the patient the root cause of their concern, really sort of touching the pain point, if you will, as well as being connected to their goals and aspirations at all times. And then the D is deciding together towards agency and wholeness. So that's like a shared decision making approach, really, but in the service of patient goals.
Emily Silverman
Thanks for listening to The Nocturnists Uncertainty in Medicine. Our core uncertainty team includes me, Emily Silverman, the Nocturnist head of story development, Molly Rose Williams, producer and editor, Sam Osborn and our uncertainty correspondent, Alexa Miller of arts practica, our student producers are Clare Nimura and Selin Everett. Special thanks to Maggie Jackson and Paul Hahn. Our executive producer is Ali Block. Our program director is Ashley Pettit. Our original theme music was composed by Asche & Spencer, and additional music came from Blue Dot sessions. Artwork for Uncertainty in Medicine was created by Eleni Debo, who is represented by folio illustration and animation agency. The nocturnist Uncertainty in Medicine was made possible by generous support from the ABIM Foundation, the Gordon and Betty Moore Foundation and the Josiah Macy Jr Foundation. The nocturnist title sponsor is the California Medical Association, a physician led organization that works to keep the doctor patient relationship at the heart of medicine. To learn more, visit cmadocs.org, the nocturnist is also made possible by support from listeners like you. In fact, we recently moved over to substack, which makes it easier than ever to support our work directly. By joining us for a monthly or annual membership, you will become an essential part of our creative community. If you enjoy the show, consider signing up today at the nocturnists.substack.com if you enjoy this episode, please share with a friend or colleague. Post on social media and help others find us by giving us a rating and review in your favorite podcast app. I'm your host. Emily Silverman, see you next week.
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Humanizing healthcare through storytelling.
podcast
Humanizing healthcare through storytelling.
podcast