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Strategies to Deal with Uncertainty in Medicine

  • Daniel M. Lichtstein
    Correspondence
    Requests for reprints should be addressed to Daniel M. Lichtstein, MD, Department of Medicine, University of Miami Miller School of Medicine, 2500 N. Military Trail, Suite 260, Boca Raton, FL 33431.
    Affiliations
    Department of Medicine, University of Miami Miller School of Medicine, Fla
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Published:January 02, 2023DOI:https://doi.org/10.1016/j.amjmed.2022.12.018
      Uncertainty is ubiquitous in clinical medicine. This applies to the diagnosis, treatment, and prognosis of illness. Patients may not be explicitly aware of the uncertainty that exists in their physicians’ minds, and unless it is honestly and clearly expressed, patients will most often believe that their physicians are certain of what is causing their symptoms and the treatment that is recommended.
      Uncertainty makes both physician and patient uncomfortable. This should not be surprising. As Gheihman et al
      • Gheihman G
      • Johnson M
      • Simpkin AL
      Twelve tips for thriving in the face of clinical uncertainty.
      discuss in their article, “Twelve Tips for Thriving in the Face of Clinical Uncertainty,” “there exists a deeply rooted cultural unwillingness to acknowledge it.”
      • Logan RL
      • Scott PJ
      Uncertainty in clinical practice: implications for quality and costs of health care.
      Therein lies the most important first step for physicians to take when dealing with uncertainty. That is, to acknowledge it.
      Medicine is a highly complex profession. We are responsible to strive to do the best we can for our patients at all times, yet diagnostic dilemmas are not uncommon and the preferred evaluation and treatment are not always clear. In addition, we have all made errors in our careers, and some of these can be traced to not acknowledging uncertainty and not having the humility or willingness to admit when we do not know something. Our patients deserve to know when we are uncertain and we should not only not hesitate to discuss our uncertainty with them, but we should embrace it.
      There typically was not a day in my career in private practice or in academic medicine when I did not feel uncertainty. The feeling could occur during the active part of my day, or at times, just prior to sleep. Very often, I would find myself thinking about a patient (or patients) just prior to going to sleep and be concerned about a decision I had made earlier in the day. This “pillow test” was something I could not deny, and it often led me to take action in some way, from calling the hospital to check on a patient, to contacting the patient first thing the following morning to see how they were doing. The common thread in each of these situations was my awareness that I could have missed something, made a wrong diagnosis or an incorrect treatment decision.
      I came to realize that the burden I felt about possibly being wrong was large. I realized that by initially not sharing my uncertainty with my patients, it resulted in more stress and worry. As Gheihman et al
      • Gheihman G
      • Johnson M
      • Simpkin AL
      Twelve tips for thriving in the face of clinical uncertainty.
      pointed out, “acknowledging our own implicit responses to uncertainty enables us to gain insight into our own reactions—both emotional and behavioral.” Acknowledging my response to uncertainty led me to embrace shared decision-making or patient-centered decision-making in medicine, and I actively engage my learners in the value of this approach. Being humble enough to say, “I don't know,” and to recognize when consultation with colleagues or consultants is indicated is critically important, and something our patients deserve.
      In addition to acknowledging uncertainty oneself, discussing the uncertainty with our patients and actively engaging our patients in shared decision-making, there are other strategies one can use and teach our learners in managing uncertainty. Always instruct a patient to call if any change or clinical worsening occurs, and be specific about what the patient should look for and how to contact you. In addition, close follow-up is crucial in dealing with uncertainty. Contacting a patient by phone as early as the day after hospital discharge or the day after an office visit can be very helpful. It allows for an accurate and current update as to how the patient is doing and whether any new or changed symptoms or signs have occurred. Arranging a follow-up appointment should also be done, and when indicated, assisting the patient to set up a visit with a consultant undertaken. As seasoned physicians will attest, the correct diagnosis may become apparent as an illness evolves, and close follow-up increases the likelihood that a physician may recognize this. Commitment to lifelong learning and intellectual curiosity are also strengths, as researching a patient's illness and possibly becoming aware of new case reports or new treatments may benefit your patients.
      If a patient is being discharged from the hospital and another physician (likely the patient's primary care physician) is going to assume follow-up, be sure to contact that physician yourself, and make clear any uncertainty that may exist about the patient's condition or plans of care moving forward. The same principle applies during a hospitalization, as care is transitioned from one shift to another or one physician to another.
      Sharing uncertainty and taking a patient-centered approach to decision-making are strategies that help to create open and trusting relationships with our patients. As Dr. Katrina Armstrong wrote in her outstanding article, “If You Can't Beat It, Join It: Uncertainty and Trust in Medicine,”
      • Armstrong K
      If you can't beat it, join it: uncertainty and trust in medicine.
      “the greatest comfort to a patient can be hearing that, regardless of clinical uncertainty, their physician will be with them no matter what the future brings.”

      References

        • Gheihman G
        • Johnson M
        • Simpkin AL
        Twelve tips for thriving in the face of clinical uncertainty.
        Med Teach. 2020; 42: 493-499
        • Logan RL
        • Scott PJ
        Uncertainty in clinical practice: implications for quality and costs of health care.
        Lancet. 1996; 347: 595-598
        • Armstrong K
        If you can't beat it, join it: uncertainty and trust in medicine.
        Ann Intern Med. 2018; 168: 818-819