The Rhetoric of Uncertainty:
Teaching Pre-Med Students to
Communicate Provisional Knowledge  

As an eight-year-old, I begged my mother to procure cow eyeballs from a butcher and proceeded to dissect them in the kitchen on a rainy Saturday. This was in keeping with my early goal to be a physician, a focus that continued until my junior year in college. At that point, it was an interest in philosophy that gradually shifted my path toward the humanities. But I never lost my deep interest in science. Rather, I now look at science through a philosophical lens. I'm intrigued by how particular ways of knowing impact science communication. These ways of knowing are often discussed as a set of skills that we need to "make sense of science," as Susanna Priest (2013) put it. Among the skills is the ability to recognize and communicate uncertainty about valid scientific claims (p. 139).

Communicating uncertainty is a crucial skill for pre-med students, who will be tasked in their careers with communicating inconclusive evidence regarding diagnosis and treatment decisions to patients, who must then in turn make decisions (Tonelli & Upsar, 2019, p. 507). Yet communicating provisional knowledge is challenging for STEM students who are accustomed to exam-focused science classes where knowledge is often presented as undebatable (Witt, Onorato, & Schwartzstein, 2021). Research into how to help medical students develop a facility with this type of communication is growing, especially since a lack of uncertainty tolerance is a risk factor for poor performance in medical school. There is increasing "interest in identifying pedagogy fostering learners' uncertainty tolerance" (Lazarus et al., 2023, p.128). Some of these new pedagogies involve storytelling and writing (Papanagnou et al., 2021), since "knowledge in such contexts is evolving and contextual" (Stephens & Lazarus, 2024, p. 1036).

With these concerns in mind, I reworked a course in Writing for Health Professionals. I had been teaching a technical recommendation report for several years. But after happening upon the research on medical students and uncertainty, my goals shifted, and I decided to teach a health communications magazine article. I had taught long-form journalism in my science writing for the public class, but for the health professions class, I made the following three changes: I limited the audience; I limited the topic; and I explicitly asked for students to engage with uncertainty in their articles.

First, I limited the audience to The New Yorker or The Atlantic readers. In these two publications, professional writers often grapple with provisional knowledge, especially uncertainty's political and ethical ramifications. Second, I asked students to write on a new or controversial medical topic. Science journalism researcher Sharon Dunwoody (1999) wrote that such topics are more likely to contain uncertain knowledge that journalists will need to address (p. 59). Third, I added several specific goals for students, stated on the assignment instructions: clarify and contextualize the degree of uncertainty in a particular research context; move beyond a simple both sides approach; and help readers to make decisions about health topics in the face of the continual knowledge production that underlies scientific research.

As an initial step in the unit, we examined how two celebrated science writers, Atul Gawande and Ed Yong, approach new and controversial topics in The New Yorker and The Atlantic. In "The Learning Curve," published in The New Yorker, Gawande (2002) struggled with the ethics of allowing residents to treat patients, an issue with no clear remedy. In class, we discussed how Gawande used personal narrative to gain the reader's trust. For example, he wrote:

This will be good, I tried to tell myself: my first real procedure. My patient was recovering from abdominal surgery...I said I would put a line in him while he was in his bed. I did not say...how tricky the procedure would be. There were 'slight risks' involved, I said, such as bleeding or lung collapse; in experienced hands, problems of this sort occur in fewer than one case in a hundred. But of course, mine were not experienced hands. And the disasters I knew about weighed upon my mind.

By neglecting to offer full transparency to his patient, Gawande resided in a morally precarious position and placed his readers in a similar position. Elizabeth Molloy and Margaret Bearman (2019) wrote that this type of "intellectual candor" is essential in helping future health professionals find the balance between vulnerability and credibility.

A complementary piece is Ed Yong's (2020) feature article in The Atlantic, "The Pandemic's Biggest Mystery is Our Own Immune System." To help his audience understand the difficulties researchers face in studying COVID-19, Yong explained a few key points about the notoriously complex immune system. Along with clear explanations of the basics, however, he delineated the unknowns. In an essay explaining a medical topic, Yong acknowledged the impossibility of fully doing so:

There's a further twist. Normally, the immune system mobilizes different groups of cells and molecules when fighting three broad groups of pathogens: viruses and microbes that invade cells, bacteria, and fungi that stay outside cells, and parasitic worms. Only the first of these programs should activate during a viral infection. But Iwasaki's team recently showed that all three activate in severe COVID-19 cases. "It seems completely random," she says. In the worst cases, "the immune system almost seems confused as to what it's supposed to be making." No one yet knows why this happens, and only in some people. Eight months into the pandemic, the variety of COVID-19 experiences remains a vexing mystery.

Yong's choices are notable in light of research on journalists' misguided tendency to reduce uncertainty in similar contexts. In "Framing Uncertainty: A Case for Purposefully Using Frames in Science Communication," Molly Simis (2013) wrote,

"When journalists cover stories of such a personal nature and immediate consequences, they have to consider and 'accommodate public sensitivities' (Nelkin, 1995, p. 105). These issues, then, are often framed as a triumphant quest for certainty (Stocking, 1999), and within that frame uncertainty is downplayed/and or eliminated" (pp. 271–272).

Yong resisted this framing. Discussing these complexities with students helps them see that false certainty is less scientific than a frank discussion of the unknown.

After this reading and discussion, students write a formal pitch, proposing their topic and approach. Next comes a drafting and peer review process, with the final article due at the end of the unit.

Final magazine articles from students varied, but overall, I was pleased with the results. Here I will give two examples, shared with permission from the students. In the introduction to "Probiotics, A Tough Pill to Swallow," Hannah Bergo integrated narrative and an honest acknowledgment of the limitations of her own knowledge:

"Hannah, Hannah, look! I just got my probiotics, look at all these bacteria!" Handing me the probiotics bottle, capsules shaking inside, I take a glance. 'A proprietary blend of 4 probiotic strains including Lactobacillus acidophilus, Lactobacillus helveticus, Bifidobacterium bifidum, Streptococcus thermophiles, and sodium (45 mg).' I give my housemate a smile, and respond 'Ya, these look good...I think.' Satisfied with my half-answer, she walks away. I'm left with awkwardness as I didn't know how to explain that her generic probiotic brand from a grocery store chain may not actually do anything for her, and likely that she wasted $30.

Here Hannah revealed her lack of knowledge, but gained the reader's trust as Gawande did: We sympathize with her ethical dilemma.

Later in the essay, Hannah addressed the uncertainty within the published research as well. She wrote,

"Unfortunately, there are mixed reviews of supplemental [probiotic] use in the literature. There are incredibly well-done studies that support the claim that probiotic supplements prevent disease, but there are also a number of studies that oppose the benefits of probiotics and even a number of poor-quality studies that need increased scrutiny."

Here she drew attention to the complexity of interpreting multiple studies and providing context about how to draw conclusions from the mixed research.

Furthermore, by addressing a topic that will be personal to many readers, Hannah knew she needs to help them make decisions. In the next section, she wrote,

Where do we go from here? That's a tough question. And one that many scientists are trying to figure out. Ideally, more regulations will be passed and more research will be funded to learn more about the role of probiotic supplements in healthy and vulnerable populations in the near future. But until then, be a careful consumer. Do your research, and look into the brand's website to see if they have any clinical studies related to the strain you are buying. It's not perfect, but it's a starting point.

I appreciate that even here, she was not saying that evaluating the scientific literature will be an easy answer. Throughout the essay, Hannah gained credibility by walking her readers through her thought process. As readers, we feel that she is learning along side us. In her self-reflection, Hannah wrote: "I hope readers will think critically about not just probiotics, but other micro-health trends and the importance of looking into professional research when a new 'cure-all' comes to market."

Another essay effectively used hedging. In "Are Phones Giving Us ADHD," Ally wrote:

"Maybe if people spent less time on their phones, their inattentive symptoms would go away. Maybe the screen time problem is just a temporary one and doesn't cause the need for a label. But even if phones really are giving us ADHD and permanently rewiring our brains, is overprescribing stimulants the only option?"

She then recommended action, even in the face of uncertainty, an important step for the type of communication required in patient-doctor interactions:

"Even though we still don't know all of the answers, the least we can do is take measures against it. According to Dr. Gloria Mark, the author of Attention Span: A Groundbreaking Way to Restore Balance, Happiness, and Productivity, the first step towards increasing your attention span is becoming more mindful of your technology use."

Ally's self-reflection importantly showed her awareness of the choices I see her making. She wrote,

"rather than definitively taking a strong stance, I encourage the reader to reflect on the matter at hand. Similarly, because there are no conclusive answers regarding whether screen time truly causes ADHD, I aimed to initiate a discussion that stimulates further research on the topic."

These successful techniques were not, of course, seen in all student final assignments—some presented inconclusive research as more conclusive than it was; others oversimplified their topics so that they could offer readers definitive advice. In hindsight, I can see that students would have benefited from a few more class discussions prior to choosing their topics. In addition, professional samples in which the authors neglect to address uncertainty would have been useful. Finally, after students create their first drafts, I will be more explicit about specific rhetorical strategies for dealing with uncertainty. I look forward to revising this assignment and helping my students with the communication complexities that their health professions will present.