One of the hardest moments in early practice is the one where a patient looks at you and asks, "So what is it?" and you are not sure.
You have done the history. You have done the exam. You have a few ideas. But none of them is clean, and the honest answer is that you do not know yet. Every instinct from school, where confident answers earned marks, tells you to pick one and sound sure. This article is about why that instinct is worth resisting, and what to do instead.
Uncertainty is the normal state, not a failure
Musculoskeletal care is full of ambiguity. Most low back pain has no single identifiable structural cause, and the tissue "diagnosis" often matters less than the prognosis and the plan. Imaging findings that look alarming show up routinely in people with no pain at all, so a scan rarely resolves the question the way patients hope it will.1 Two people with the same label can respond completely differently to the same treatment.
Medicine more broadly has started to say this out loud. A widely discussed perspective in the New England Journal of Medicine argued that intolerance of uncertainty drives over-testing, over-treatment, and clinician burnout, and that learning to tolerate it is the next real shift in training.2 That applies as much to a chiropractor or physiotherapist in a Winnipeg clinic as it does to a hospital physician.
The students and new graduates we work with are usually surprised by how often an experienced clinician's internal monologue is "I'm not sure yet, but here is how I'll find out." That is not a gap in knowledge. It is the knowledge.
Why false confidence is the riskier option
Picking a label to sound decisive has costs that are easy to miss in the moment.
The first is anchoring. Once you have said "it's your SI joint" or "it's a disc," you and the patient both start filtering new information through that label. Findings that fit get noticed; findings that do not get explained away. Cognitive-error research in diagnosis repeatedly identifies premature closure, settling on an answer before it is earned, as one of the most common ways clinicians go wrong.3
The second is the story the patient leaves with. A confident but wrong structural explanation can follow someone for years. Patients remember what clinicians tell them about their bodies, and a sentence like "your spine is unstable" can shape fear and behaviour long after the appointment is forgotten.4
The third is trust. Patients are better at detecting bluffing than new clinicians assume. If you commit firmly to one explanation at visit one and change it at visit three, you have spent credibility you did not need to spend. If you said from the start that you were working between two or three possibilities and would narrow it down, the change is expected and your credibility goes up.
How to say it well
"I don't know" on its own is not enough. It leaves the patient holding the uncertainty with nothing to do about it. The skill is in what comes after. A useful structure looks like this:
- What you have ruled out. "I've checked for the things that would need urgent attention, and I'm not seeing any of them." This is often the most reassuring thing you can say, and it is usually true.
- What you are considering. "There are two likely explanations for this, and they're managed a bit differently."
- How you will narrow it down. "I'm going to start with the approach that fits both, and how you respond over the next two weeks will tell us which one it is."
- What they can do meanwhile. A clear plan for movement, activity, and what to watch for.
Notice that this is still a confident conversation. You are confident about the process, the safety screen, and the plan. You are honest about the label. Patients can tell the difference, and the research on therapeutic alliance suggests that the quality of that relationship is itself linked to better outcomes in rehabilitation.5 Alliance is built on being believable, not on being certain.
It also helps to remember that in musculoskeletal care, the prognosis is often more useful to the patient than the diagnosis. "This type of thing usually settles over six to twelve weeks with the right loading" answers the question they actually care about, even when the tissue label is still open. We have written more on that distinction in diagnosis versus prognosis.
Building the muscle
Tolerating uncertainty is not something you either have or do not have. It develops, and a few habits speed it up.
Write down your working hypotheses, plural, in your notes, and the test you expect to separate them. Reassess on purpose, not just when the patient complains. Treat a response that surprises you as information rather than embarrassment. And find a mentor who will tell you when they are unsure, because watching a skilled clinician hold uncertainty calmly is the fastest way to learn that it is survivable.
In our clinic, we try to model this with students and associates: reasoning out loud, naming the competing possibilities, and letting the reassessment decide. It is part of how we structure assessment and care for every patient, not just the complicated ones. If you are early in your career and considering a mentorship setting, our article on moving from student to clinician reasoning covers some of the same ground.
Saying "I don't know yet" is not the end of your clinical reasoning. Done well, it is the clearest evidence that reasoning is happening.
References
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
- Simpkin AL, Schwartzstein RM. Tolerating uncertainty: the next medical revolution? N Engl J Med. 2016;375(18):1713-1715.
- Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
- Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527-534.
- Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90(8):1099-1110.