How to handle uncertainty
Studies have yet to tease out how physicians' tolerance of uncertainty affects their behavior and decision making, and even their sense of burnout.
Feeling more uncertain lately? It's not just you.
“As we learn more and our society changes, the uncertainty just grows. It doesn't seem to shrink much,” said Martha S. Gerrity, MD, MPH, PhD, FACP, a professor of medicine at Oregon Health & Science University in Portland.
While physicians' tolerance of uncertainty has long been studied, it has become an increasingly hot topic in the wake of COVID-19, said Arabella Simpkin Begin, MD, PhD, director of studies in clinical medicine at Lincoln College, one of the constituent colleges of the University of Oxford in the U.K.
“What COVID has really shown in technicolor is how much we can't control … and I definitely think there's been an increased interest in recognizing how important it is that we learn to live with uncertainty,” she said.
Internal medicine physicians already have a leg up on some other specialists in their tolerance of uncertainty, according to Dr. Gerrity, who as a graduate student developed the Physicians' Reactions to Uncertainty (PRU) Scale to measure physicians' affective reactions to uncertainty.
“The majority of the studies suggest that people who are in generalist careers have a greater tolerance for uncertainty than those who go into very narrow specialties, such as some of the surgical fields and dermatology,” she said.
Physicians may have tended to conceal their uncertainty in the past, but that has shifted over the past 10 to 20 years as medical education has evolved, Dr. Gerrity noted. “I was a master test taker, and there always was a right or a wrong answer,” she said. “With some of our new ways of evaluating knowledge and skills, we're moving a little bit away from that.”
Still, for the most part, medical education is chock-full of tests with right or wrong answers. “So you end up feeling like there's got to be a right answer here, and that just ups the anxiety around uncertainty,” she said.
What's the evidence?
Studies have yet to tease out how physicians' tolerance of uncertainty affects their behavior and decision making. Overall, their results are variable, said Dr. Gerrity, who stays on top of the research by receiving Google alerts when studies on physicians' reactions to uncertainty are published and hopes to do a systematic review.
One recent study of 217 primary care physicians at Massachusetts General Hospital in Boston found that those with a low tolerance for uncertainty were less likely to order diagnostic tests (namely, complete blood cell counts, thyroid tests, basic metabolic profiles, and liver function tests), according to results published in September 2022 by JAMA Network Open.
“Previous researchers found that low tolerance of uncertainty is associated with increased test-ordering tendencies, so the idea is that if you don't tolerate uncertainty well, you want to sort of order more and more tests to try and be certain,” said Dr. Begin, the study's lead author. “But actually, what we saw was the opposite.”
She offered a possible explanation. “If you're ordering less tests, in a sense what you're doing is closing down the diagnostic reasoning process earlier,” Dr. Begin said. “And one of the worries about physicians with low tolerance of uncertainty is that you risk premature closure on decision making because you want to get out of that space of uncertainty.”
That's where intolerance of uncertainty could hurt patient care. “We know that premature closure on diagnostic reasoning is one of the leading causes of diagnostic error, and obviously, there are all sorts of downstream negative ramifications for the patient and the health care system with diagnostic error,” Dr. Begin said.
Dr. Gerrity said she was not at all surprised by Dr. Begin's results. However, she noted that the study was limited by using only one of 15 items from the PRU Scale.
The study also found that primary care physicians with medium versus high tolerance of uncertainty had some worse patient experience scores, although these associations were not present in comparisons between physicians with low versus high uncertainty.
Communicating uncertainty is something that virtually everyone struggles to do, Dr. Begin said. “But recognize that that probably really does have an impact on the patient experience and not feeling heard and listened to.”
Dealing with uncertainty
It may seem that more tolerance of uncertainty is always a good thing. But in a February 2021 article in the Journal of General Internal Medicine (JGIM), Dr. Gerrity and coauthors made the case that tolerance of uncertainty is not necessarily positive or negative.
At either extreme, both tolerance and intolerance of uncertainty have their flaws, according to the paper. On the one hand, a clinician who is extremely tolerant of uncertainty may be less likely to ask colleagues for help; on the other, the anxiety of a clinician who's extremely intolerant may lead to hesitancy to act.
Too little tolerance of uncertainty also poses a threat to clinicians' well-being, noted Dr. Begin. She led a survey study, published in April 2021 by JGIM, which found that physicians with low tolerance of uncertainty were more likely to burn out, less likely to be satisfied with their career, and less likely to be engaged at work compared with those with high tolerance of uncertainty.
“But equally, if you have too much tolerance of uncertainty, I think there's a risk that you … don't make a decision if you're trying to sit too comfortably with it,” Dr. Begin said. “At some point, you have to be able to make a decision in the face of uncertainty. And I think that's one of the big challenges.”
To help physicians avoid the pitfalls of uncertainty, Dr. Gerrity's JGIM paper offered three corrective virtues: courage, diligence, and curiosity. “Courage corrects for the tendency to ‘flee’ from uncertainty too hastily; diligence mitigates the impulse to give into it too easily; curiosity inspires practitioners of all tolerance levels to confront it productively,” the authors wrote.
As a general internal medicine physician who practices inpatient and outpatient medicine in an academic setting, Dr. Gerrity rated her tolerance of uncertainty as fairly high. “Even though I have some degree of uncertainty about a situation, I at least have confidence that I can act safely,” she said.
For example, it may be unknown whether a patient's shortness of breath is due to acute decompensated heart failure. “But let's give the patient diuretics and see how they do overnight, and that'll help us know if we're headed in the right direction,” Dr. Gerrity said. “And knowing not to do anything too crazy when I'm uncertain, like giving diuretics is not too crazy because you can always give fluids back.”
Dr. Begin, on the other hand, said she still struggles with uncertainty as a clinician. “My husband jokes that he thinks the reason I'm so interested in it is because I am so bad at dealing with uncertainty myself,” she said.
This kind of self-reflection can help clinicians proactively plan for uncertainty in their management and follow-up, said Dr. Begin, who wrote a paper offering 12 tips on managing uncertainty, published in the March 2019 Medical Teacher. Recognizing and quashing unnecessary uncertainty is one of her top recommendations.
“Minimizing unnecessary uncertainty, I think, is a really helpful way to feel like you have some control,” Dr. Begin said. “So you may have some uncertainty, but actually you could solve that by more knowledge or looking something up or asking someone.”
Impacts on medical education
Historically, medicine has suppressed and ignored uncertainty, Dr. Begin said. But increasingly, medical education is recognizing that tolerance of uncertainty should be a core competency and professional milestone, she said. For example, the Association of American Medical Colleges includes recognizing ambiguity as part of clinical care and responding by using appropriate resources to deal with uncertainty in its Core Entrustable Professional Activities for Entering Residency.
“As physicians, we're really well poised to help students and trainees and less experienced colleagues embrace uncertainty,” Dr. Begin said. “One of the critical steps is teaching students, trainees, people on your team that medicine is characterized by uniqueness and ambiguity.”
In general, newer trainees have a harder time dealing with uncertainty, as people tend to be more anxious when they're not confident about what they're doing, Dr. Gerrity noted. “There are studies that support that … the interns are much more anxious than the third-year residents are,” she said.
But as residents go on to become early-career physicians, they often have more confidence in uncertain situations, said Dr. Gerrity, who is also section chief of general internal medicine at the VA Portland Health Care System. “As I watch our junior members join our section … they will often turn to other members in our section and say, ‘What do you think about this?” she said. “It really is wonderful that they feel comfortable doing that.”
This requires that physicians have the courage to share, not hide, their uncertainty, said Dr. Gerrity. “I am very upfront when I'm staffing a resident clinic or working with an inpatient team of residents about my own uncertainties or our uncertainty as a team and how I would deal with that,” she said. “I have the courage to speak up and say, ‘I don't know, let's ask for help.’”
Clinicians must also have the diligence to follow through, perhaps by consulting a subspecialist or delving into the research, Dr. Gerrity said. “If you're uncertain and are a bit anxious about the situation, imagine what it must be like for the patient you're working with,” she said. “If you are going to say, ‘I'm not sure about what's going on,’ that has to be followed up with the steps you're going to take.”
Throughout the process, physicians must also be curious about the patient's experience, Dr. Gerrity said. “I think patients need to hear that we've listened to them … and heard what [they've] described and are anxious about,” she said.
Ultimately, clinician educators should promote curiosity over certainty, Dr. Begin added. “Ask why and how, not what and when—questions that require higher-order thinking and don't necessarily have a set answer,” she said.