Thinking in Gray

Life is not always black and white. It's a million shades of gray.

Photo by Ray Hennessy on Unsplash

As physicians, we are trained to make decisions grounded in data, science, and established clinical guidelines. And yet, the real art of medicine resists absolutes. Complex medical decision making often exists in the space in between black and white: in the more ambiguous graphite shades of gray.

Advancing beyond traditionally well-defined, two-dimensional black and white views into nuanced, multi-dimensional grey zone thinking is essential for practicing medicine effectively. It allows us to weigh relative risks and benefits, consider individual patient needs, and embrace the inevitable uncertainties inherent to the human condition.

I once had a very experienced physician colleague who anxiously sought my advice two to four times per day. I immediately recognized the quickly paced footsteps, the abrupt “rap rap rap” three tap tepid knock on my office door. This doc’s medical board exam scores made my scores look like dog food. He was brilliant. He knew the “facts” of psychiatry inside and out. Better than most. BUT. When there were equally significant pros and cons to each choice, where there was no obvious best answer, where there could be real potential dangers (and benefits) with each option, he struggled. He had difficulty living in the gray.

In medicine, answers are rarely absolute. Whether deciding to start an antidepressant, increase dose, change medication, add medication, interpret neuro psych evaluations, or integrate lab results, every decision involves weighing relative risks and benefits, often with no perfect answer. To make matters more challenging, an acceptable “risk” often varies from patient to patient. This makes shared decision-making conversations involving the patient’s perspective even more critical to high quality care.

When my smart physician friend was unsure of what to do next, he would often send his patients to get expensive, time-consuming neuro-psychological evaluations. He hoped the long, detailed life summary would magically illuminate the right clinical path. He was sure that somehow clinical certainty would come neatly wrapped in a bow at the end of the 17-page typed summary, like a little doctor jack-in-the box ecstatically popping off the page to confidently exclaim, “Go with Prozac!”

He was always bitterly disappointed. To his surprise, learning all the intricate details of his patients’ upbringing, their childhood likes and dislikes, their former pets’ names, their favorite foods, and the details of all of their traumatic memories did not provide additional clarity on whether to choose Depakote over Lithium. Having too many facts often complicates decision making instead of simplifying it.

Too much black-and-white thinking in medicine can also lead to the opposite problem: physician overconfidence, and patient-public mistrust. Assuming there is always one clear “right” or “wrong” answer prevents us from considering alternative approaches or perspectives. For example, another physician friend of mine was absolutely convinced that electroconvulsive shock therapy (ECT) was unsafe. Because he was unwilling to consider the profound mood benefits that ECT provides in context with the associated risks, many of his patients with severe depression were never offered the option of this powerful, life-saving treatment. Sad.

Our patients are smart. They seek (and deserve) nuanced care that considers their unique circumstances. Not a one-size fits all model. As physicians, we should tailor each patient discussion to the individual. We all say that. But we don’t always do it. Deep doctor-patient conversations will lead to a myriad of potential “correct” clinical pathways. Absolutism erodes trust when it fails to account for individual patient needs, values, and cultural belief systems. If all medication options/treatments are equally safe, effective, and evidence based, then the best choice is the patient’s choice.

Living in the gray means accepting there is no perfect solution-only a decision that most aligns with the patient’s current needs and goals, and best available evidence at the time. Inviting patients into this decision-making conversation makes our job easier, and more enjoyable. It also reduces provider stress and burnout. Clearly communicating the positives and negatives of potential medical decisions helps us acknowledge the limits of our own medical knowledge, communicate transparently with our patients, and ultimately build stronger and more rewarding therapeutic relationships. Learning to accept imperfection- helping our patients make the best imperfect choice given their circumstances-frees us from the constant paralysis of overanalyzing. Turns out, there are many yellow brick roads that lead to the Emerald City of health. It’s much more fun to choose the best one with several tour guides by our side.

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Finally, the principal of living in the gray applies to relationships, personal growth, and all decision-making. People and situations are inherently complex. No one is entirely “good” or “bad.” If you can’t think of a single positive quality or deed of someone you dislike, it doesn’t mean they are all bad. It means you either A) don’t know them well enough or B) you choose-either consciously or unconsciously- not to acknowledge the good because it reinforces your existing world view. Similarly, if you can’t think of a single negative quality about someone, it simply means you haven’t discovered, or acknowledged, their fatal flaw(s).

This is a common phenomenon known as confirmation bias, where we choose to acknowledge facts or data that reinforce our existing beliefs while discounting, ignoring, or twisting data points that conflict with our current world view. Everyone is guilty of confirmation bias. To see it in action most clearly, simply observe any conversation about politics.

We can’t rid ourselves of confirmation bias. But we can become more attune to it. To work on reducing your own confirmation bias, think of three positions you passionately support. Then, for each position, become as educated as possible on the opposing viewpoint, attempting to make an artful, genuine persuasive argument in support of the opposing view. This in turn will help you to be more open to considering other perspectives. It ultimately cultivates a more empathic, malleable, and comprehensive understanding of the world around you and those you share it with.

Life in the gray doesn’t mean abandoning principles or ignoring evidence. It means embracing uncertainty as a natural part of both medicine and life. Rather than waiting for perfect clarity, it’s about asking, “What is the best (not perfect) choice I can make right now with the information I have?” It’s about understanding that the “right” choice might be different for different people, even with the same surrounding facts.

In medicine, this mindset helps us make better decisions for our patients. In life, it fosters growth, resilience, and compassion.

The gray areas of life and medicine can be uncomfortable. They require us to make choices in the face of ambiguity, admit that we don’t have all the answers, seriously consider differing viewpoints, and take calculated risks. But they are also where the greatest opportunities for learning, growth, and human connection lie. Rejecting black-and-white thinking and embracing complexity helps us navigate the many challenges of medicine and life with a little less emotional reactivity, and a little more wisdom, empathy, flexibility, and grace. Instead of seeking perfection or one singular answer, strive to make thoughtful, informed decisions that consider all angles.

The amazingly complex wonder of life, and the true joy of medicine, reside in the cool shades of gray. Join me there.

-Lauren