How can I be certain?

Uncertainty: the state of not knowing.  Being a health professional: realising you cannot know everything and adapting to the state of uncertainty as appropriate for the context. 

Uncertainty is a state in which I spent much of my time as a general practitioner.  As a medical student my scientific training led to my seeing education as moving towards certainty as my knowledge grew. I was taught to interpret a patient’s constellation of symptoms and signs obtained through a history and examination to define a list of possible diagnoses (known as a differential diagnosis).  A doctor subsequently works through this list by elimination with the help of test results, if necessary, until the patient’s condition is certain.  It’s a diagnostic puzzle which needs solving.  

The need for certainty was reinforced by the assessments that we had in the 70s and 80s.  One example was the ‘long case’. The student is allocated a patient and given 45 minutes with them to come to a differential diagnosis.  The student then ‘presents’ the patient to the one or two examiners (who had not observed the interaction between student and patient), gives the differential diagnosis, states what tests are needed and then what the management should be for the final diagnosis. We thought it unfair if the diagnosis were left uncertain.  It wasn’t unfair though in our opinion, but rather luck, if the patient revealed the diagnosis to us during the 45 minutes.  We believed there would always eventually be a correct answer that scored the maximum marks.  

In real life of course medicine is messy.  Being able to live with uncertainty requires skill and experience.   Health professionals must learn how symptoms change over time and how many people improve without a firm diagnosis.  If a doctor finds uncertainty challenging then there is a tendency to over-investigate to avoid missing a serious condition, which would not only be a poor outcome for the patient but might lead to a complaint against the doctor.  Some health professionals, such as GPs, are more comfortable with this situation: the wait and see approach and the uncertainty of clinical practice. 

It took me a while and many patient interactions to learn to be comfortable with uncertainty. Patients also find uncertainty challenging; it can make them feel vulnerable and anxious.  They usually want to know what is wrong and what the implications of their symptoms are. So, good communication is important to support the patient and oneself.  When you know patients over time, as a GP can do, mutual trust occurs, and uncertainty is more manageable: there is time to wait and the opportunity for review.   I have always tried to be honest with patients and to admit when I don’t have an answer or a prediction as to what may happen.  Studies looking at uncertainty have mixed results in that some show increased patient satisfaction if a doctor expresses uncertainty and some that patients’ satisfaction is decreased.  The ideal appears to be to reach a state of a shared consciousness of uncertainty[1] through sharing information between patient and professional and a shared decision as to what to do next – which may be nothing at the present time. 

I did find as I got older uncertainty again became difficult to cope with, to some extent because as an educator I was spending a lot less time in clinical practice.  Moreover, when a health system is under strain, time is at a premium and ‘waiting and seeing’ isn’t always an option, and appointments aren’t easy to schedule. 

It is possible to become so crippled by uncertainty that you can no longer function as the GP or health professional you want to be.  You feel the need for a second opinion far more frequently or to order more investigations ‘just in case’.  There comes a time for retirement or psychological support.  

To be continued…

[1] Han PK, Klein WM, Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decis Making 2011; 31(6):828-38. doi: 10.1177/0272989×11393976. 

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