Uncertainty is a fundamental feature of the medical diagnostic process. Whilst it provokes distress in patients, and discomfort in physicians, uncertainty is integral to the process of diagnosis. According to Debra Swoboda in her paper titled Negotiating the diagnostic uncertainty of contested illnesses: physician practices and paradigms, uncertainty is more evident in the so-called ‘contested illnesses‘ such as chronic fatigue syndrome and multiple chemical sensitivities, but it shadows every medical diagnosis.
Whilst medical uncertainty should be a familiar phenomenon to doctors, Medicine as a whole has unfortunately long denied its pervasive presence. Medicine’s unhealthy relationship with diagnostic uncertainty was highlighted by Arabella Simpkin and Richard Schwatzstein in their paper titled Tolerating uncertainty – the next medical revolution? In this article, they asserted that Medicine has a traditional ‘deep-rooted unwillingness to acknowledge and embrace‘ uncertainty, preferring to ‘consciously and subconsciously’ ignore and suppress it. They particularly criticised the classical medical imperative to make a diagnosis at all costs, often by ‘transforming a patient’s gray-scale narrative into a black-and-white diagnosis that can be neatly categorized and labeled‘. The authors acknowledged that uncertainty is ‘unsettling‘ for physicians in whom it ‘instills a sense of vulnerability, and by which it may ‘project ignorance to patients and colleagues’. They nevertheless maintain that certainty is an illusion which is incompatible with the reality that ‘doctors continually have to make decisions on the basis of imperfect data and limited knowledge‘.
There are several factors responsible for the denial of uncertainty that bedevils medical practice. For example, Amit Ghosh highlighted lack of knowledge, resources, and time as contributors to clinical uncertainty in his paper titled On the challenges of using evidence-based information: the role of clinical uncertainty. The authors of Professional Judgment: A Reader in Clinical Decision Making also attributed intolerance of uncertainty to the difficulty doctors have in distinguishing between their imperfect individual knowledge, and the limitation of current medical knowledge. They added that doctors also deny uncertainty because of their belief in the myth of physician infallibility; the power of the culture of medical professional authoritarianism; and the fear of loosing out to alternative practitioners.
Beyond the disquiet that it provokes, uncertainty may also evoke a ‘stress reaction‘ in doctors which heightening its negative influence. This was pointed out by Lance Evans and David Trotter in their article Epistemology and uncertainty in primary care: an exploratory study. In another paper titled Understanding medical uncertainty: a primer for physicians, Amit Ghosh also described how the intolerance of uncertainty generates anxiety by making doctors ‘perceive ambiguous situations as sources of threat‘. The stakes of diagnostic uncertainty are however much higher for patients than for their doctors because; as Simpkin and Schwatzstein pointed out, the denial of uncertainty is a source of potential harm and a threat to patient safety because it leads to premature closure of the diagnostic decision-making process’, and because it triggers the ‘excessive ordering of tests’.
To mitigate the impact of the intolerance of uncertainty, the authors of Professional Judgment: A Reader in Clinical Decision Making advised physicians to ‘admit uncertainty to themselves and their patients’; to learn ‘the language of uncertainty‘; and to use statistical terminologies such as probabilities. Simpkin and Schwatzstein, on the other hand, urged the medical profession to cultivate a tolerance for uncertainty and ‘a curiosity about the unknown’. John Biehn, in his paper titled Managing uncertainty in family practice, advocated the adoption of a ‘more open doctor-patient relationship, whilst John Rizzo, in his paper titled Physician uncertainty and the art of persuasion, recommended the following:
- Teaching physicians to ‘accept and cope with uncertainty’,
- ‘Forging consensus through expert panels‘,
- Using decision analysis tools such as medical practice guidelines
Other strategies and techniques of reducing uncertainty were explored by Amit Ghosh in his two papers cited above, and these included:
- Establishing trust with patient
- Applying meticulous history-taking and evaluation
- Adhering to the highest clinical assessment standards
- Critically appraising the literature
- Applying the best-available evidence-based information
- Using shared decision-making
In the next blog post, we will look at the single strategy that encapsulates the best approach to dealing with diagnostic uncertainty, and that is diagnostic flexibility.