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  • Writer's pictureRyan Allen

Finding clarity in ambiguity

As many may know, I’ve been grappling with a confusing case of new onset diabetes over the last few months. In earlier posts, I’ve detailed some of the frustrations I’ve had with my patient experience. My principal concern has been the struggle I’ve had with convincing myself that I have the stereotypical pathology of type 2 diabetes, which includes metabolic syndrome and insulin resistance. This is the diagnosis that my physician has insisted on giving me, admittedly by process of elimination. Those who know me know that I do not exactly fit this profile, nor can I accept something that just objectively does not make sense. In many ways, the evidence has continued to contradict this T2D diagnosis. Yet, my persistent urge to discover the truth has been met with, in my opinion, closed-minded resistance on the part of my doctor, who seems determined to more or less “close the case” as it stands.

While I’ve previously outlined some of the limitations of medicine exemplified by my case, I recently gained some additional insights on this topic from a conversation with one of my professors that I felt were undoubtedly worth sharing.

Of course, the conversation began purely on topics of molecular and cell biology, covering a couple of different subject matters where I’d had particular curiosity in recent weeks and hoped to glean insights from his expertise in the field. I felt incredibly fortunate to hear some of his thoughts (from an accomplished research scientist and not a medical doctor or clinician) on these topics as they pertained to my personal diabetes case. In fact, he even hypothesized about the possible biological basis of my high blood sugar. Expressing doubt over the metabolic T2D theory, he posed an alternative viewpoint that actually appeared to reasonably fit my presentation and observations from my continuous glucose monitor (CGM).

Though this is still a completely unconfirmed and inconclusive hypothesis, it truly felt like a weight lifted off my shoulders, at least to some degree. After months of serious difficulty in contemplating possible metabolic bases of my insulin resistance, “mistakes” I had made with my health... thinking maybe it was this or that I had done, and knowing deep inside that it just didn’t make sense... I finally had at least some working explanation to build upon. The biology is unfortunately beyond the scope of this post and will be included in a future one, but it makes more sense than any other reasoning I’ve heard to date. Although this input was clearly invaluable for me after months of frustration with my care, it actually wasn’t even the key takeaway I had from the conversation, which really speaks to the importance of this next point for me.

As the conversation shifted towards my own care, it became less about the hard science and more about the nature of medicine, and in particular clinical practice. I’ve mentioned in the past how I acknowledge that this diabetes diagnosis, while an unfortunate, serious threat to my long-term health and longevity, does actually present an opportunity. An opportunity to experience the practice of medicine from the patient perspective, not to mention in a fascinating scenario of metabolic dysregulation that I’ve long held an interest in better understanding. In our conversation, I was able to reflect on what this opportunity has given me, namely in regard to the things I want and do not want to hear from my doctor.

So, this was the takeaway: sometimes, we all need to be able to acceptingly say “I don’t know.” From a patient’s perspective, this may not seem like something we all want to hear. I think in general, our society tends to hold this belief that science consists entirely of exact, perfectly defined concepts. Unfortunately, not all cases in medicine fall into generic categories from textbooks, and each case must be considered on an individual basis. The doctor simply will not always be able to give a definitive diagnosis in every case (in all likelihood, my case included).

The clinician’s role in this then becomes more nuanced. The reality is that a majority of people will view science and medicine in the light I’ve just mentioned, and fully expect a well-defined answer from their doctor. Some, such as myself, would rather know the entirety of the truth, all of the facts and possibilities that my physician can give me, no matter how complicated or abstract things may get. We can start to see how it becomes a difficult situation to navigate, with the clinician deciding how to explain a diagnosis in a way that is tailored to that individual’s goals from the diagnosis. Going back to my treatment as an example, I feel my doctor leaned too far towards the “definitive diagnosis” end of the spectrum, probably from having grown accustomed to a patient population who wants this sort of response. Having sensed my dissatisfaction with this in our interactions, though, it would have been more appropriate for the doctor to provide me with everything she knew about my circumstance. I feel that for me in particular as a patient, she should have admitted that she could not say with certainty the reasoning behind my high blood sugar, rather than give a clear answer (T2D) that she didn’t necessarily know to be true.

To be completely honest, I will admit that I think finding this balance may be the toughest challenge I personally face in my path to becoming a successful clinician. It frustrates me that science is not always algorithmic. Growing up, I was always math-oriented in grade school because I loved the idea of having a set correct answer. But as it turns out, sometimes in medicine and in the real world, we all have to settle for ambiguity. It will be tough for me to explain to patients that I simply do not know, but at the end of the day, it is the patient’s right to obtain the entirety of the truth. The more seamless the physician can make this access to the honest knowledge and insights they have to offer, the more “accessible” health truly becomes.


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