Dealing with uncertainty

in primary care
What is the AGENDA ?
 Introduction
 Define uncertainty and risk?
 Importance of dealing with uncertainty?
 Factors contribute to uncertainty?
 Strategies to deal with uncertainty?
 Wisdom;
 The scientist Franklin wrote:
"Nothing in life is certain except
death and taxes".
Letter from Benjamin Franklin to Jean Baptiste, 13th November 1789, recorded in The works of Benjamin Franklin.
 Certainty, Risk & Uncertainty

 Certainty:
• A situation in which the outcome that will occur is known.
Examples??

 Risk:
• A situation in which all possible outcomes and the probability of
occurrence are known , but you do not know which outcome
shall surely occur.
Examples??

 Uncertainty:
• A situation in which the possible outcomes or probability of the
outcomes is unknown, or both the possible outcomes and
probability of outcomes are unknown. Examples??
http://en.wikipedia.org/wiki/Uncertainty
 Positioning Uncertainty & Risk

Risk and
Uncertainty Uncertainty Risk

Probabilities Some Knowledge Probabilities

[and Outcomes] Of Probabilities [and Outcomes]
Unknown [and Outcomes] Known

Source: Casavant, Kenneth, Infanger and Bridges

 Uncertainty
 Dealing with uncertainty is a core competence for
family physicians.(1)
 Approximately two thirds of all primary care patients
present at some point with symptoms that remain
unexplained or ambiguous despite adequate medical
work-up.(2,3)
1. Dinant GJ: Diagnosis and desicion making: Undifferentiated illness and uncertainty in diagnosis and
management. In Oxford Textbook of Primary Medical Care (Volume 2) Edited by: Jones R, Britten N, Culpepper L, Gass D,
Grol R, Mant D and Silagy C. Oxford, Oxford University Press; 2004:201-203.

2. Kroenke K, Price RK. Symptoms in the community. Prevalence, classification, and psychiatric comorbidity. Arch
Intern Med. 1990;150:1685–9.

3. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy and outcome.
Psychosom Med. 1989;86: 262–6.
 Do you think it is important ? Why?
 Uncertainty may contribute to variability in physician
practice patterns including excessive use of
diagnostic tests, treatments and other resources(1)

 It also contributes to patient and physician anxiety,

dissatisfaction, and regret (2)

 Uncertainty complicates quality of care standards,

malpractice judgments, informed consent, and
resource allocation (3)
1/Kassirer JP. Our stubborn quest for diagnostic certainty: A cause of excessive testing. N Engl J Med 1989;320:1489–91.
2/Johnson CG, Levenkron JC, Suchman AL, Manchester R. Does physician uncertainty affect patient satisfaction? J Gen Intern
Med 1988;3:144–9.
3/Eddy DM, Billings J. The quality of medical evidence:Implications for quality of care. Health Affairs 1988;4:74–89.
 Billy Anderson has a mystery illness;
hospitalized for 15 months; no diagnosis
Examples from daily practice:
 Medicine;
• FUO
 Surgery;
• acute appendicitis
 Obs/gyn;
• Recurrent abortions
• Infertility
 Paedics;
• abdominal migraine
 Diagnosis of exclusions
 Factors causing medical
uncertainty;
 Patient factors;  Physician Factors:
1. Patient present early in the 1. Poor communication skills
disease, less symptoms. 2. Inappropriate assessment
2. Uncertainty in history of probability
3. Inappropriate prioritization 3. Physician’s tolerance to
of history uncertainty
4. Test variability 4. Test interpretation
5. Variable response to 5. Inability to apply evidence-
treatment based treatment
6. Access to variable sources 6. Inability to appraise best
of information on same evidence
topic 7. Influence of medical
7. Influence of society organization and local -
practice environment
AK Ghosh: Understanding Medical Uncertainty: A Primer for Physicians, review article, JAPI SEPTEMBER 2004,52; 739-742.
 Interesting ?
 In an audiotape review of physicians and
patients interviews it was found that
physicians used expressions of
uncertainty in 71% of the time.

Gordon GH, Joos SK, Byrne J. Physician expressions of uncertainty during patient encounters. Patient Education & Counseling.
2000;40:59-65.
 The chain of uncertainty

AK Ghosh: Understanding Medical Uncertainty: A Primer for Physicians, review article, JAPI SEPTEMBER 2004,52; 739-742.
Uncertainty and future specialty
 Medical students who  Medical students who
do not like uncertainty can deal with uncertainty
ultimately choose; will chose;
• Anesthesia, • Internal Medicine
• Surgery, and • Family medicine
• Radiology • Psychiatry

Gerrity MS, White KP, DeVellis RE, Dittus RS. Physicians’ reactions to uncertainty: Refining the constructs and scales.
Motivation and Emotion 1995;19:175-91.
 Physician’s perception of
uncertainty in their daily work
 Least
 Urologists and Orthopedists

 Psychiatry, Family Practice and General Medicine

 Profound

Gerrity MS, Earp JAL, DeVilles RF. Uncertainty and professional work: Perceptions of physicians in clinical practice. Am J Sociol
1992;97:1022-51.
Patient prefer behavioral expression
of uncertainty than verbal expression
 Verbal expressions of  Behavioral expressions
uncertainty i.e., using of uncertainty
expression like, • using a computer to find a
• ‘ I don’t know,’ answer,

• ‘ let’s see what happens’, • asking another physician for

advise ,
• ‘ I haven’t come across this
• referring to a hospital
before’, etc.,

Patients were most disturbed when the physician asked a

nurse for advice (behavioral expression of uncertainty)

Ogden J, Fuks K, Gardner M, Johnson S, McLean M, Martin P, Shah R. Doctors expressions of uncertainty and patient
confidence. Patient Educ Couns 2002;48:171-76.
 Strategies for handling medical
uncertainty (1)
1) Define the diagnosis and explain the signs and
symptoms and its relation with the disease

2) Emphasize and eliminate alternate diagnosis which the

patient might be concerned of

3) Describe the possible course of the illness and scope of

the treatment

4) Identify and negotiate key issues which concern the

patient and the physician
Hewson MG, Kindy PJ, Van Kirk J, Gennis VA, Day RP. Strategies for managing uncertainty and complexity. J Gen
Intern Med 1996;11:481-5.
 Strategies for handling medical
uncertainty (2)
5) Prioritize the plan, assess patient’s understanding and willingness
to comply

6) Emphasize that alternative diagnosis will promptly be evaluated if

symptoms change or new ones arise

7) Take action to eliminate worrisome diagnosis

8) Set up reasonable follow-up appointment to assess change of signs

and symptoms

9) Negotiate a plan with the patient to deal with any situation that
require immediate action
Hewson MG, Kindy PJ, Van Kirk J, Gennis VA, Day RP. Strategies for managing uncertainty and complexity. J Gen
Intern Med 1996;11:481-5.
Thank You Questions??