Bioethics Forum Essay
Omicron, the Legacy of Renée Fox, and the Uncertain Practice of Medicine
It is more than ironic that Renée C. Fox, the doyenne of medical sociology, died last year during the Covid-19 pandemic. While she was not a victim of the coronavirus, Fox’s life was forever altered by another pandemic virus, polio which she contracted just a few years before that scourge was tamed by the Salk vaccine. Fox endured the post-polio syndrome for most of her life, a state that might be considered analogous to long Covid. Nonetheless, her early experience with serious illness, recovery, and rehabilitation was a mixed blessing. It sparked a brilliant career leaving us with a scholarly inheritance which has enriched our understanding of medical training and clinical uncertainty. Her legacy is of particular importance as the novel coronavirus has turned the most seasoned practitioners into novices compelled to provide patient care humbled by uncertainty. Like the pandemic, uncertainty, growing confidence, and the return of doubt come in waves. The Omicron variant is just the latest twist in this plot.
In 1957, Fox wrote a pioneering essay entitled “Training for Uncertainty” in The Student Physician. Using participant observation, a methodology that she helped to develop, Fox embedded herself with medical students at Cornell University Medical College to watch their development over four years of medical school. These observations were enriched by diaries that students were asked to keep during their training. The result is a richly textured narrative of their transformation as they gained skills and confidence, progressing from their preclinical years to the wards.
Fox described three types of uncertainty faced by the medical student. The first is engendered by incomplete mastery of the vast amount of available medical knowledge. The second stems from limitations in what we actually know. These two aspects of uncertainty can conspire to create a third type of uncertainty in which it is difficult to differentiate the former from the later.
In the preclinical years, diagnostic and therapeutic uncertainty begins with the student’s introduction to the basic sciences and their first autopsy. While the student yearns for generalizable “laws and theories” to gain mastery over a wealth of information, they are confronted by a regime of “possibilities and probabilities” and individual variability among patients. In a journal entry that could have been written today about the protean coronavirus, a student grapples with “how one person will contract a disease he’s been exposed to, while another one won’t. The person may have a chill, or not; the agent may be virulent or not; and that determines whether pneumonia will occur or not . . . .”
Despite evidence of the uncertain state of medical knowledge, as they progress through the third year, students start to gain mastery of what they have been taught. With growing confidence in themselves they gain a “manner of certitude,” as Fox put it, that allows them to make clinical judgments. But their ambivalence persists: even as their outward mien projects confidence, inwardly they are gaining a deeper appreciation of the contingent nature of clinical practice, though they would never admit their doubts. Fox quotes a third-year student who put it this way, “I’m sure that on the higher levels of medicine you do admit your ignorance and avoid stereotyped thinking. But we are at the point now where you have to believe in the rule rather than the exception.” Over time, surety and doubt learn to coexist, in an uneasy tension that allows for clinical work to proceed over the course of one’s career.
This relationship between uncertainty and growing clinical confidence has been upended by Covid-19. With a pressing clinical need to act and to provide care in the face of their ignorance about a novel disease, even the most seasoned clinician will fall back on feelings of uncertainty they experienced while in training. They become like medical students again, asking themselves what they know and what they think they know. This developmental regression is compounded by fears about their own well-being and that of their family in the face of a new and dangerous pathogen.
Over the course of her career, Renée Fox returned to her original work on uncertainty. Forty years ago, she wrote a long essay in the Milbank Quarterly tracing the evolution of uncertainty since her field work as a participant observer in the 1950’s. Fox’s musing were unexpected. Despite its phenomenal success in the postwar era–typified by the establishment and growth of the National Institutes of Health–science had bred uncertainty that transcended the clinic and infiltrated every fiber of American life. The co-existent promise and peril of new technologies like recombinant DNA, transplantation, genetic testing, and nuclear energy led to disquietude about biohazards and even fears of existential annihilation. She observed that “health, illness, and medicine appear to be the epicenters of the increased malaise about uncertainty, and the anxiety about the danger and risk that have surfaced in society.” In response came new fields like bioethics, as well as increased regulation and litigation.
Fox’s revisiting of uncertainty provides a perspective against which to refract our own times. When she wrote in 1980, society’s uncertainty was about emerging technologies and their promise and peril, though it seems the emphasis was on peril. Today, we worry about nature and emergent new diseases typified by the coronavirus and whether science will continue to provide a remedy and if society will accept these ministrations.
And yet it is a curious arc. The societal concerns that Fox gave voice to about emerging science are echoes of the fears that prevent their fuller dissemination today, and with that the mitigation and eventual end of the pandemic. That the genome of the novel coronavirus was sequenced in a month and mRNA vaccines were ready within a year is the culmination of the emergent molecular medicine which caused such angst in decades past. Sadly, while the science has succeeded to great effect, segments of our population remain vaccine-hesitant and science phobic. I suspect Fox would not be surprised that human nature, and not the nature of the virus, is what continues to fuel the pandemic.
Joseph J. Fins, M.D., M.A.C.P., F.R.C.P., is the E. William Davis Jr. M.D. Professor of Medical Ethics and a Professor of Medicine at Weill Cornell Medical College, Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law and a Visiting Professor of Law at Yale Law School and a member of the Adjunct Faculty at the Rockefeller University. He is a Hastings Center fellow and member of the Center’s Board of Trustees.
Renee Fox dealt with her postpolio syndrome remarkably well for decades. The fact that she accomplished so much and contributed so much, is a testimony to her grit, determination and sense of humor. It was a privilege to know her.
A lovely tribute to a great lady. Renee Fox was also a wonderful mentor to many students. She was particularly kind to me at the University of Pennsylvania, and we had great conversations. Our lives had both been shaped by early sickness, for her Polio; for me a car accident at age ten. We both embraced uncertainty and got on with life. She was very interested in my work on emergent genetic technologies, I think because my background didn’t come from medicine but from ecology, therefore she was interested in a different worldview.
While the author may marvel at the genetic vaccines developed in under a year, Fox would have remembered the the 1957 & 1968 flu pandemic vaccines that were developed in 5 months. She perhaps may have had a wry smile for the scramble (and subsequent ethical debate over ventilators), when mere oxygen turned out to be the better first treatment.
Thank you for a lovely tribute to a great teacher and scholar.