Uncertainty and not being able to handle uncertainty appropriately have costs for patients and health professionals.
Practising in isolation is now uncommon though there are still clinics with a solo health practitioner. Practising within a trusted team may help with uncertainty as discussing patients with colleagues and seeking different points of view draws on a wealth of diverse experiences and professional knowledge. Unfortunately, when a healthcare system is under pressure, time for formal and informal meetings is rare. Team members are less likely to be available for a timely consultation when advice is needed.
There was a time some decades ago when there was space at the end of morning surgery for a coffee/tea break, which provided an opportunity to discuss uncertainty arising from consultations. Getting a timely 2ndopinion can now be difficult. Sometimes it is easier to order a blood test or X-ray to gain some thinking time. Sometimes there is pressure, real or imagined, to do something other than wait. This may be because asking a patient to return for follow-up means extra cost for them in time and/or fees, or there are no free appointments for several weeks.
I was interested to read an article that analysed 20 consultations between patients and GPs in England. The authors define uncertainty as being medical or existential.[1] Medical uncertainty reflects limitations in medical knowledge, which can be gaps in the health professional’s own knowledge or the total of what is currently known through research by the scientific and medical community. As a GP if I don’t know something I can try to look it up – I have the tools to do this and search engines on my practice computer. This of course takes time if the question is complicated, and the evidence is conflicting.
Existential uncertainty is uncertainty of being, which is a difficult concept and one less likely to be discussed in health professional training. We cannot know the future for certain and we cannot control it. Our predictions, and in medicine our prognoses, are also based on our own experience and those of others.
I have had a reluctance to prognosticate during my career – particularly to suggest how long a person may live or a potentially curable condition may last. My mother was told by a doctor before she married my father in the 1950s than she would be fortunate to have five years with him, following his operation to collapse half of one of his lungs to treat tuberculosis. He died at the age of 93 in 2018. My grandfather was also advised after World War 1 and his time in the trenches that he would not live long. His marriage lasted fifty years. False reassurance is also detrimental when the future is uncertain.
Both types of uncertainty may be precipitated by a patient with symptoms that do not fit with any pattern of illness or disease that the health professional recognises, or that are diagnosed through medical tests. Such symptoms have been referred to as MUS (medically unexplained symptoms). They are frustrating for patient[2]and doctor.[3] With time (but how long?) the MUS or medical knowledge may change, and a diagnosis becomes clearer. Obviously, neither patient nor doctor wants to miss a serious underlying condition. How much uncertainty can be borne by both?
GPs interact with patients with MUS frequently and many are referred for a specialist opinion. MUS is a label that is not typically shared with patients as it may seem derogatory and judgmental: ‘The doctor thinks it’s all in my head’; he thinks I’m making it up; she thinks there’s nothing wrong with me’. Another term is functional disorder which implies that there is a problem with how the body functions rather than a disease affecting its structure. If used, the labels MUS and functional disorder need to be carefully explained to patients, who should not see them for the first time written on a test referral.
Unfortunately, people with MUS are often referred to as frequent attenders, heartsink patients, doctor shoppers and somatisers, which I feel says more about the attitudes of the professional, who uses such labels, than the person who consults. O’Dowd coined the term heartsink in the UK in 1988[4] and regrettably it is still sometimes used today.
We should be thinking of how a person labels the professional. If you feel a doctor is uncaring, dismissive, or arrogant you may decide to choose another GP, a different type of health professional, or a complementary therapist in the hope of finding one to listen. Or perhaps you avoid clinical interactions in the future.
There are differences between advising a patient that ‘I don’t know what the problem is at this point but let’s meet again next week and see what is happening’; ‘I don’t know what the problem is at this point, but I will definitely find out’ followed by a string of investigations, and ‘I don’t know what the problem is but you needn’t worry about it.’ It’s important not to make promises that might not be kept. Fundamentally, the patient-health professional relationship is based on good communication. Health professionals may learn to cope with uncertainty over time and through discussions with colleagues, reflecting on practice. We need to remember that patients aren’t taught to cope with uncertainty. They must live with the concerns and the symptoms and need appropriate support.
The study on uncertainty in clinical encounters1 indicates that GPs may indirectly express uncertainty rather than be explicit about it. The authors feel that this is related to the culture of medicine that fosters in doctors an unwillingness to admit uncertainty, which has been described in other work.[5] Similar to many novice doctors I wasn’t comfortable to express uncertainty at the start of my career as I felt that patients would lose confidence in my abilities. Uncertainty seemed to suggest ignorance. As I grew into my GP role, I was better able to admit to being uncertain and not embarrassed about looking things up – though looking things has become easier with desktop computers rather than out-of-date textbooks.
[1] Lian OS, Nettleton S, Wifstad A, Dowrick C. Negotiating uncertainty in clinical encounters: A narrative exploration of naturally occurring primary care consultations. Social Science & Medicine 2021; 291.
https://doi.org/10.1016/j.socscimed.2021.114467
[2] Jackson AL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Int Med 2001; 134:889-897.
https://doi.org/10.7326/0003-4819-134-9_part_2-200105011-00013
[3] Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Int Med 2001; 134: 897-904.
https://doi.org/10.7326/0003-4819-134-9_part_2-200105011-00014
[4] O’Dowd TC. Five years of heartsink patients in general practice. BMJ 2002; 325: 1342-1345
https://doi.org/10.1136/bmj.297.6647.528
[5] Mackintosh N, Armstrong N. Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions. Sociol. Health Illness 2020; 42:(S1),1-20.
Health professional education and practice 