Uncertain

TH E WI SDO M
A N D W ON DER
O F B EI N G
U N SU RE

MAGGIE JACKSON

uncertain.indb 3 6/28/23 9:32 AM

 FOR PROMOTIONAL USE ONLY
Please do not print or distribute material without written permission from
the publisher.

An imprint of Globe Pequot, the trade division of The Rowman & Littlefield
Publishing Group, Inc.
4501 Forbes Blvd., Ste. 200
Lanham, MD 20706
www.rowman.com

Distributed by NATIONAL BOOK NETWORK

Copyright © 2023 by Maggie Jackson

All rights reserved. No part of this book may be reproduced in any form or by any
electronic or mechanical means, including information storage and retrieval systems,
without written permission from the publisher, except by a reviewer who may quote
passages in a review.

British Library Cataloguing in Publication Information Available

Library of Congress Cataloging-in-Publication Data

Names: Jackson, Maggie, 1960– author.

Title: Uncertain : the wisdom and wonder of being unsure / Maggie Jackson.
Description: Lanham, MD : Prometheus Books, [2023] | Includes bibliographical
references and index. | Summary: “Featuring cutting-edge research and in-depth
reporting, this paradigm-shifting book shows us how to skillfully confront the
unexpected and unknown, and how to seek not-knowing in the service of curiosity,
wisdom, and discovery”—Provided by publisher.
Identifiers: LCCN 2023008346 (print) | LCCN 2023008347 (ebook) |
ISBN 9781633889187 (cloth) | ISBN 9781633889194 (epub)
Subjects: LCSH: Uncertainty.
Classification: LCC BF463.U5 J33 2023 (print) | LCC BF463.U5 (ebook) |
DDC 153.4—dc23/eng/20230616
LC record available at https://lccn.loc.gov/2023008346
LC ebook record available at https://lccn.loc.gov/2023008347

The paper used in this publication meets the minimum requirements of

American National Standard for Information Sciences—Permanence of Paper for
Printed Library Materials, ANSI/NISO Z39.48-1992

uncertain.indb 4 6/28/23 9:32 AM

 c h a pt e r o n e

Mind under Fire

The Shadow Side of Knowing

Whoever cannot seek the unforeseen sees nothing,

for the known way is an impasse.
— h e rac l itu s

T he surgery is going smoothly. The patient lies anesthetized in a Toronto

operating room waiting for one of Canada’s top surgeons to join the
team. A junior surgeon just ten weeks into the job is making the initial in-
cision, exposing a bright-red abdominal cavern and a cancerous liver set for
partial removal. Slicing into this three-pound organ, home to 13 percent of
the body’s blood supply, is akin to navigating a minefield. Thought by the
ancient Greeks to be the seat of emotion, the liver is a nexus of life that is
critical to hundreds of vital functions centered mostly on detoxifying the
body. For the hand holding the scalpel, it is an organ of perilous surprise.
But the senior surgeon, a cancer geneticist and one of the country’s leading
hepatobiliary specialists, knows the drill. He has been doing this for so
many years that his mind sometimes strays mid-operation to the rest of his
busy day, although his pace doesn’t slacken. He takes pride in his efficiency
and expects a routine resection this time. Despite the disease’s advance, the
sick man’s chances are good.
Perched in a nearby waiting area, the senior surgeon munches a bagel
and assesses the case with a colleague who will be observing the procedure.
I listen in, preparing to accompany them into the operating room. I have
made my way here to witness expert thinking in action and to see what

uncertain.indb 3 6/28/23 9:32 AM

 4   u ncer t ain

role uncertainty might play in the most urgent of times. Is a surgeon who
hesitates in a crisis foolhardy or heroic? Are some heights of excellence
best left to the resolutely sure? The surgeon’s tale offers critical lessons of
promise and folly in an era when the world can upend from one hour to
the next. Who will we look to for wisdom in the next free fall? Who are the
sages of our day? Popping a last bite of breakfast into his mouth, the senior
surgeon lingers before heading off to don mask and gown and get the job
done. “Most of our business deals with avoiding problems,” he says. “Most
surgery, and I guess most things in life, are like that.”
Moments later, his scrubbed hands held high, he bursts into the sur-
gery and saunters up to the operating field, sizing up his quarry: a cluster
of hard, white tumors scarring the liver’s right lobe. To excise the cancer, a
kind of siege warfare must unfold, as the surgeons endeavor to isolate and
remove the diseased lobe without harming the healthy left half. The crux of
this work will lie in dividing three major blood vessels and a bile duct that
variously connect the heart, the liver, and the intestines. Like rivers that split
into two branches, these bodily supply lines each fork just inside the liver;
by sealing off and then cutting one branch of the hepatic artery, portal vein,
bile duct, and hepatic vein, the surgeons can keep the cancer-free half of the
liver and the patient alive. But if they mistakenly cut the main trunk of any
of these anatomical structures, the man may quickly bleed to death.
The trick is finding what matters amidst layers of tissue, fat, and blood
so intricate and anatomically individual that even expert surgeons some-
times lose their bearings. Articles in the field warn practitioners of myriad
anatomical variations that no medical textbook fully depicts. “We don’t
like to say, ‘What the hell is that?’ too often,” jokes the senior surgeon.
“But we do say it occasionally. It’s always a bad sign.” Surgeons must be very
careful, wrote Emily Dickinson, When they take the knife! / Underneath their
fine incisions / Stirs the Culprit—Life!
Like saboteurs on a moonless night, the surgeon and his student creep
forward, excavating the liver and surrounding tissue with a cautery as the
sour scent and smoke of burning flesh pervade the room. The young doctor,
new and cautious, works slowly. The senior surgeon guides her, tells war
stories, orders the nurses about, and grows impatient. Halfway through an
operation, he usually begins watching the clock, a habit now typical in a
field besieged by lean profits, overworked staff, and increasingly complex

uncertain.indb 4 6/28/23 9:32 AM

 M ind u nder Fire    5

diseases. “All the pressures [in health care] are on the side of production,”
notes safety expert Peter Pronovost. At this hospital, any operation running
overtime is tagged with a red flag; such tallies of efficiency can influence
a surgeon’s future allotment of cases. For a profession schooled to be re-
lentlessly bold, the aim is clear: speed is the gold standard and doubt an
unwelcome intrusion. In medicine, to deal with uncertainty is to “make it
go away,” says one physician-scientist, “then we’re done.”
“So this is the right artery,” the senior surgeon announces. “It’s big, ac-
tually,” he adds, suddenly taken back. At this juncture, the pair is working
at the organ’s lower end to uncover a trio of close-packed vessels, including
the hepatic artery that ferries oxygenated blood from the heart into the
liver. Spotting a hefty bit of artery here might show that they have found
their target, the vessel’s expendable right branch, albeit in extra-large size.
(The patient is a tall man.) Or instead, the structure’s generous size could
indicate they are in dangerous territory and may be about to sever the ar-
tery’s main stem. The senior surgeon, mind made up, orders the trainee to
seal off and cut the structure in hand. But she insists on first temporarily
closing off the section of artery in question with a clamp and then feeling
for a pulse in the vessel’s nearby left branch to check its viability—a caution
he calls “paranoid,” then begrudgingly permits. Confirming his call, she
makes the cut.
Yet the encounter is telling, the observing doctor later explains. A re-
nowned scientist and surgeon in her own right, Carol-anne Moulton is my
guide to the critical judgments unfolding before me. Formerly the senior
surgeon’s student and now his relentlessly questioning peer, she has spent
more than a decade probing quandaries like these: when, amidst high-
stakes predicaments, much is not as it seems. A global authority on sur-
gical expertise whose influence extends far beyond medicine, Moulton is
at the forefront of one of cognitive science’s most challenging endeavors:
decoding how we can wrestle a solution from the clutches of a fast-evolving
problem, how we can grapple with spiraling unknowns.
That day, with a clock ticking and a life at risk, we would see the expert
mind on the fly, all dexterity and decision, and witness its precarious limits.
He didn’t want to spend two or three minutes clamping the artery, Moulton tells
me later. He was happy to take that chance and divide it for the sake of efficiency
and time. Speed matters, for the longer the operation, the higher the risk of

uncertain.indb 5 6/28/23 9:32 AM

 6  u ncer t ain

complications, especially in complex procedures. “There are times when you

need to keep moving,” says Moulton. Yet hasty assurance under fire, she ar-
gues, is the dangerous Siren call of our day. Calm and athletic with a strong
jaw, an easy smile, and a penchant for questioning the status quo, Moulton
is gaining accolades for challenging our outdated assumptions about the
nature of superior performance. Her quest is helping to reveal a dramatic
new understanding of how true expertise is achieved and why, more than
ever, we need such prowess.
“Cut along the line,” orders the older surgeon, pointing to the increas-
ingly visible boundary between a healthy russet left lobe and the now-
darkening right liver. “Go back and forth, good,” he says. He is approaching
the most critical point in the endeavor, the division of the crucial duct car-
rying digestive fluid called bile into the intestines. Would he honor the
situation’s complexities, recognize that danger is near? Not for the first time
during the operation, Moulton interjects to urge caution. But the surgeon
plows on. “Faster, faster,” he says. The diseased lobe is nearly free. And that’s
when Moulton’s warnings come home.

uncertain.indb 6 6/28/23 9:32 AM