Intended for healthcare professionals

Editor's Choice

Navigating medicine’s grey areas

BMJ 2019; 367 doi: (Published 24 October 2019) Cite this as: BMJ 2019;367:l6153
  1. Navjoyt Ladher, clinical editor
  1. The BMJ
  1. nladher{at}

Learning to operate in grey areas is part of the science and art of medicine. As clinicians we must develop the skills to cope with uncertainty and to continuously adapt our practice in response to new information.

Several recent articles should help you navigate some of the grey areas in medicine, from an Analysis that challenges long held views about TB infection being life long (doi:10.1136/bmj.l5770) to an education article on blood tests that can help differentiate cancer from benign causes in people with non-specific symptoms (doi:10.1136/bmj.l5774).

Though there is a strong temptation to simplify grey areas, overlooking important nuance can cause more confusion. The debate about legalising assisted dying is one such example. Katherine Sleeman and Iain Chalmers want to see the discussion extended to include people living with unbearable suffering (doi:10.1136/bmj.l6093). Assisted dying law exists along a continuum, they say, and reducing public debate to a binary yes or no is a dangerous oversimplification.

Equally dangerous, say David Healy and Dee Mangin, is oversimplification in detecting medication related harms (doi:10.1136/bmj.l5777). For too long, they say, we have relied on clinical trials for information on adverse events rather than trusting the judgment of doctors and patients, resulting in long delays for side effects to be recognised, which compromises patient safety.

Continuity of care can help, particularly for people with long term conditions. Rebecca Rosen makes the case for prioritising continuity in primary care, even though it is often overlooked by politicians looking to score points in favour of improving access (

But perhaps the most important consideration is how we share uncertainty and complexity with patients. Gemma Venhuizen tells us about a hospital in the Netherlands where shared decision making has reduced rates of surgery (doi:10.1136/bmj.l5900). “Well informed patients often choose quality of life above being operated on at all costs and extending their life span to the maximum,” reports a hospital manager.

Better informed patients deciding what matters to them most? We can at least be certain that is a good thing.

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