Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1529e1533

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Diabetes & Metabolic Syndrome: Clinical Research & Reviews

journal homepage: www.elsevier.com/locate/dsx

Tools to manage medical uncertainty

Amit K. Ghosh a, *, Shashank Joshi b
a
Mayo Clinic College of Medicine, Rochester, 55905, MN, USA
b
Consultant Endocrinologist, Joshi Clinic, Lolavati and Bhatia Hospital, Mumbai, Maharashtra, India

a b s t r a c t
Keywords: Background and aims: Despite an explosion of evidence-based guidelines, many decisions in clinical
Medical uncertainty practice remain shrouded in uncertainty. Physicians could view ambiguous situations as a source of
Physician
threat. Uncertainty results from personal lack of knowledge, limits of current medical knowledge and the
Managing uncertainty
inability to distinguish between the two. The purpose of this review is to study the prevalence, effects
and management of medical uncertainty in clinical practice.
Methods: PubMed search for articles on prevalence and management of medical uncertainty.
Results and conclusion: Intolerance to uncertainty among physicians may result in increased test-
ordering tendencies, failure to comply with evidence-based guidelines, guide career choices, and
result in decreased comfort with geriatric, chronic illness and psychological problems. Factors causing
variability of disease management includes: patient factors(inappropriate prioritization, risk aversion,
expectations), physicians factors(lack of knowledge, intolerance to medical uncertainty, limited re-
sources, time constraints), biological variability of patient, health system factors, patients comorbidities,
technological and media influences contributing further to unrealistic expectations. Physicians’ per-
ceptions of uncertainty in their daily work vary considerably. Urologist and orthopedic surgeons reported
less uncertainty in their daily routine compared to psychiatrists, family practitioners and general in-
ternists. Effective methods of managing uncertainty include, consensus building among physicians from
3 or more specialties regarding patients problem, building trust between patients, their physicians and
health care systems, thoughtful evaluation with exclusion of worrisome diagnosis, apply evidence-based
information with effective risk communication, negotiating management strategies with patient and
establishing regular follow-up with personalized feedback. (e 245 words).
© 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.

1. Introduction outcomes of medical interventions are unpredictable.

Medical uncertainty is present in every patient encounter.
Medical school curricula encourage students to solve chal- Regardless of our obsession with certainty due to easy access to
lenging clinical cases through the use of evidence-based algo- medical literature, technology and quest for a right answer,
rithms. Consequently, many physicians are accustomed to using inability to handle medical uncertainty can be distressing [3].
reductionist approaches in solving complex problems [1]. While Although a strong fund of knowledge and critical thinking ability
traditional diagnostic and therapeutic approaches for solving are important, these skills alone are insufficient for managing
medical problems seem straightforward, they may lead physicians challenging patients. Additional skills include the ability to criti-
to approach real-world patients with a false sense of certainty. cally appraise and utilize current evidence (which is continuously
Indeed, physicians in training and practice are often frustrated by evolving), and to recognize medical uncertainty when it arises.
elusive diagnoses and failed interventions [2]. Nevertheless, expe- Indeed, we believe that familiarity with uncertainty in medical
rienced physicians often learn that diagnostic tests are imperfect, practice will enhance patient and physician satisfaction and
the natural histories of most diseases are uncertain, and the improve outcomes.
In this article we will describe various aspects of uncertainty,
highlight the prevalence of uncertainty in medical practice, and
* Corresponding author. Mayo Clinic College of Medicine, W-17 B, GIM, 200 First
review the impacts of uncertainty on physician-patient in-
Street, SW, Rochester, 55905, MN, USA. teractions. Additionally, we will provide practical tips for dealing
E-mail address: [email protected] (A.K. Ghosh).

https://doi.org/10.1016/j.dsx.2020.07.055
1871-4021/© 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.
1530 A.K. Ghosh, S. Joshi / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1529e1533

with medical uncertainty.

2. Types of medical uncertainty

Numerous terms have been used to describe uncertainty in

medical practice. These include: intolerance and ambiguity, risk
averse, uncertainty, probability of disease, and unclear cases [4].
Budner defined intolerance to ambiguity as the tendency to
perceive ambiguous situations as threatening and tolerance to
uncertainty as the tendency to perceive ambiguous situations as
desirable [5].
Beresford identified 3 types of uncertainty: (1) technical un-
certainty resulting from inadequate scientific data from medical
history, physical examinations and laboratory test or physicians
lack of knowledge; (2) personal uncertainty resulting from un-
awareness of patient wishes; and (3) conceptual uncertainty arising
from an inability of applying concrete criteria to abstract situations
[6]. While training, experience and effort may adequately address
technical and personal uncertainty, conceptual uncertainty may
linger.
In the sociology literature, 2 forms of uncertainty in medical
prognosis emerge: clinical uncertainty, which is based on the
practical difficulties in diagnosis and prognosis; and functional
uncertainty, which exists after a diagnosis has been established, but
the patient remains uncertain about the chance of future recovery
due to lack of health care information and education (despite being
aware of the diagnosis) [7,8]. These forms of uncertainty may affect
the patient adherence with intervention and medical outcomes.

3. Prevalence of medical uncertainty

The true prevalence of uncertainty in medical practice is un-

certain, however, numerous clinical and sociological studies pro-
vide some insight. For example, the cause of unintentional weight
loss remains unidentified in 24e26% of cases and the cause of
chronic pancreatitis remains unidentified in 30e40% of cases
[16,17]. Regarding physician factors the use of phrases the reflect
uncertainty such as “I don’t know” and “it’s not clear” are
commonly observed. Indeed, in a study of audio-tapes of patient-
physician interviews, physicians used expression of uncertainty
71% of the time [11]. Moreover, the prevalence of uncertainty
probably varies by specialty. Gerrity et al. [18] in a study of 410
Fig. 1. The chain of uncertainty of patient-physician encounter.
physicians in 14 specialties enquired about their perceptions of
uncertainty in their daily work. Not surprisingly, urologist and or-
thopedic surgeons reported less uncertainty in their daily routine
compared to psychiatrists, family practitioners and general in-
ternists (Table 1).

4. Causes of medical uncertainty

Fox [9] reported that uncertainty in medical students stems

from personal ignorance, limits of available medical knowledge,
and an inability in distinguishing between the two. Eddy [10] de-
scribes the patient-physician encounter as a “chain of uncertainty”
that involves several links. Links in this chain include biological
variability of the case, uncertainty of the physician, the motives of
the consultation, the bias of the patient and the physician, medical
errors, variability in medical opinions, and the differing values of
the patients and physicians (Fig. 1). Language and culture discor-
dance between patient and physician may also pose challenges to Fig. 2. Factors affecting physicians’ response to uncertainty (modified from refercnce
[14]).
the physician in explaining uncertainty (see Fig. 2).
Factors that cause variability of disease management derive
from patients (e.g., inappropriate prioritization, risk aversion and constraints), biological variability among patients, health system
unrealistic expectations), physicians (e.g., lack of knowledge, factors, patient comorbidities, and technological and media
intolerance to medical uncertainty, limited resources and time
 A.K. Ghosh, S. Joshi / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1529e1533 1531

influences that contribute to unrealistic expectations [10e13]. The prove to be more unsettling to patients than what they might
potential causes of medical uncertainty are listed in Table 2. perceive by subjectively observing us handle their case (behavioral
Notably, advances in technology and new scientific knowledge, uncertainty).
shifting health care delivery systems, and evolving evidence-based Most physicians however respond to resolving uncertainty by
guidelines, all contribute to the prevalence of uncertainty in med- action, and studies have revealed that this behavior could lead to
ical practice [13] (see Table 2). In fact, uncertainty frequently bor- increased hospital admission and ordering of more tests [20].
ders around the edges of new knowledge, and larger bodies of Marked practice variability among different regions has also been
knowledge create a greater burden of uncertainty [14]. attributed to difference in physicians’ decision making capability in
Han and colleagues [15] have described a taxonomy of uncer- moments of diagnostic and therapeutic uncertainty.Despite
tainty in health care based on the three main issues surrounding evidence-based guidelines, there remains uncertainty among the
health care namely i) scientific, ii) practical, and iii) personal issues. preferred course of action among physicians [13,21].
Scientific uncertainty is traditionally disease based while practical Uncertainty remains prevalent throughout the practice of
and personal uncertainty is based on system and patient-related medicine, and causes anxiety in patient’s [22] and physicians [23].,
issues respectively. Scientific uncertainty deals with diagnosis, In a review of 88 audiotape reviews of patient - physician
prognosis, causal explanations and treatment recommendations. communication in a primary care setting in Portland, Oregon, in
Practical uncertainty deals with processes of care and caregivers 95% of the medical encounters, uncertainties surrounding the
(hospital quality and competence of physicians). While personal medical diagnosis were not clearly stated during the process of
uncertainty deals with the psychosocial and deeper issues per- informed consent [24]. Failure to acknowledge the uncertainties of
taining to one’s existence (meaning of life, goals in one’s life, rela- an intervention to yield a diagnosis and completely address
tionship with family, disruption in family due to illness.) possible complications could potentially mislead the patient in the
process of informed consent with implications towards malpractice
5. Effects (outcomes) of uncertainty in medical education and [22].
practice Surgeons encounter uncertainty routinely in their patients in
the operation theater. Cristancho et al. [25] reported in a
Experienced physicians soon come to realize that uncertainty constructivist qualitative study including observation and in-
surrounds most aspects of medicine, from making a diagnosis, terviews of seven staff surgeons during 26 surgical cases pre
choosing among the different treatment modalities and assessing identified as ‘likely challenging.’ The authors used template anal-
the outcome of a disease. Young physicians may fail to make the ysis to identify instances of uncertainty and inductive analysis to
distinction between the goal (absolute certainty of making a understand and define the concepts of uncertainty. According to
diagnosis and a plan of treatment) and the realistic standards of the participants factors like novelty of the situation, difficulty in
current practice of medicine [3]. When faced with uncertainty in predicting outcome, and difficulty in deciding the course of action
practice physicians may mistakenly construe this as an error on characterize an uncertain situation in surgeon.
their own part and this could affect the physician-patient Personal tolerance to ambiguity and uncertainty seem to play a
relationship. considerable role in medical students when it comes to career
A patient’s response to physician’s uncertainty has been found choice. Amongst medical students there is a higher intolerance of
to be highly dependent on the technique that is employed by the uncertainty in those who ultimately choose Anesthesia, Surgery,
physician in expressing uncertainty. Ogden et al. [19], reported that and Radiology as future career options as compared to medical
patients found verbal expressions of uncertainty, i.e., using expres- students who choose to go to Internal Medicine and Psychiatry [26]
sion like, ‘I don’t know,’ ‘let’s see what happens’, I haven’t come Medical students who were intolerant to uncertainty had a nega-
across this before’, etc., more bothersome than behavioral expres- tive response to patients with hypochondriasis, geriatrics, and pa-
sions of uncertainty (i.e., using a computer to find a answer, asking tients with psychological problems [23]. Inability to resolve and
another physician for advice, referring to a hospital for admission). understand medical uncertainty could confuse and scare medical
When patients were asked to rank their concern about various students from seeking out careers in primary care (General Medi-
expressions of uncertainty, they were most disturbed when the cine, Pediatrics, family practice, psychiatry), thereby depleting
physician said, 1) ‘let us see what happens,’ or 2) ‘that they don’t future reserve of generalists who deal with undifferentiated ill-
know’ or 3) asked a nurse for advice (behavioral expression of nesses. Inability to deal with uncertainty could also lead to diffi-
uncertainty). Hence, ‘what’ and ‘how’ we say something might culty in coping with medical complexity.

6. Tools for managing medical uncertainty

Table 1
Physician Perception of uncertainty among different specialties.
Physicians should do three things to help patients manage with
Specialties Mean ratings* uncertainty [27e29]. Firstly they need to be honest with patients
Psychiatry 7.4 and inform them that despite of developments in the area of
Family medicine 6.8 diagnosis and treatment there lays considerable uncertainty about
General Internal medicine 6.7 the future. Physician should consult other physicians to come to a
Pediatrics 6.0
Obstetrics- Gynecology 5.7
consensus on the patient’s problems and acknowledge their own
Hematology- Oncology 5.5 biases in management.
Rheumatology 5.5 Secondly acknowledge that the emotional distress experienced
Gastroenterology 5.2 by the patient and their relatives and thirdly help the patient and
Cardiology 5.1
relatives be mindful of the realities of their lives and live with their
General Surgery 4.9
Dermatology 3.8 uncertainty at the present time.
Anesthesiology 3.4 Physician should understand the core values of the patient and
Orthopedic Surgery 3.3 take it under consideration when talking about the uncertainty
Urology 3.2 surrounding prognosis [30]. Patients might value quality of life
* 10 point Likert scale; least uncertainty(1), greatest uncertainty (10). more than the quantity of life hence these patients might be more
1532 A.K. Ghosh, S. Joshi / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1529e1533

Table 2
Factors resulting in medical uncertainty.

1) Biological variability of disease Genetic predisposition

Concomitant diseases
Undefined factors
2) Patient factors Uncertainty in history
Patient’s risk aversion
Variable response to treatment
Non-compliance to treatment
Misunderstanding of treatment
3) Physician factors Inappropriate probability- estimation
Physician’s tolerance to- uncertainty
Inability to interpret test -limitations
Inability to appraise best evidence
Poor communication skills
Reluctance for 2nd opinion
4) Health systems Inadequate organizational support
Bureaucratic obstacles
Frequent audits
Time constraints
5) Mass Media Encouraging absolute certainty
Inappropriate risk communication (relative risk rather than absolute risks)
Overemphasizing involuntary risks(natural disasters)
Hyping unrealistic expectations

concerned about the uncertainty of future well-being rather than prescribed treatment. In order to effectively acknowledge the gap
life expectancy. in one’s argument, the doctor must preemptively anticipate the
Physicians need to generate trust in their patients, which often flaws that the patient might see in the case. De Souza [34] stressed
alleviates the patient’s anxiety in moments of clinical uncertainty. the importance of understanding both the issue that is being
Trust is often developed after the patient self-evaluates their phy- negotiated as well as the person that is being negotiated with. By
sicians competence and degree of compassion. Patients develop a taking into account the patients’ beliefs and their positions, doctors
presumptive or expectant trust even prior to their first encounter can quickly understand what aspects of the recommended plan the
which is developed often by their previous experience, secondhand patient might take most issue with. The doctor can then take steps
knowledge from others or trust in general [31]. Subsequent expe- towards quickly assuaging those issues. Being honest about the
riential trust is developed by knowing the physician over a period holes in one’s position, followed by quickly addressing how those
of time. holes are being addressed will help the patient understand that
Current emphasis on practicing evidence-based medicine is their doctor has a detailed understanding of both sides and is
often stressed as a useful adjunct to reduce uncertainty. In an effort making an informed recommendation. This understanding be-
to reduce variability and optimize care for patients in conditions of tween the patient and the doctor will improve the relationship
certainty and uncertainty, physicians must adopt a rational holistic between them, leading to a negotiation that is more equivocal and
and probabilistic, and not reductionist approach to patient care. pleasant.
Katon [32]has detailed how the biomedical model is an inadequate Our practical suggestion to deal with uncertainty would include
model for patient care today, and we should find ways to apply case discussion among physicians to sort out gaps in current evi-
social science to clinical practice in order to elevate the ways in dence or establishing a committee of three or more specialists from
which doctors can cater to their patient’s needs. same or different specialties to come to consensus. The treating
Clinical expression and management of most chronic illness physician can communicate the consensus decision while engaging
involve addressing the patients biomedical and psychosocial in effective patient-physicians communication to generate trust in
environment and their expectations of managing their chronic their patients, educating the patients and supporting the patient
illness. when diagnosis and treatment options remain uncertain despite
The techniques that experienced physicians have used include a exhaustive evaluation (Table 3.).
combination of qualitative and quantitative approach and the use There are no studies till date, directly studying the effect of this
of tacit reasoning when dealing with uncertainty. Tacit knowledge intervention on physicians’ perception on uncertainty.
refers to the knowledge and skills that are often used by experts in Current approaches in managing uncertainty therefore entails a
practice but are rarely articulated. Hewson and colleagues [33] probabilistic approach to illnesses. Often treatment has to be
identified nine strategies that they felt were effective in managing initiated in the absence of a firm diagnosis, hence the values and
uncertainty in primary care. These strategies dealt with shared feelings are considered crucial for diagnosis and treatment and
decision-making, meticulous evaluation, exclusion of relevant shared decision making process [36].
worrisome differential diagnosis and establishing trust with pa-
tient Faculty physicians were noted to use a greater portion of these
7. Conclusions
strategies as compared to second year residents (61% versus 44%
respectively) [33]. Since elimination of uncertainty remains virtu-
There are several factors which result in medical uncertainty
ally impossible, one needs to practice and familiarize oneself with
during a clinical encounter, including 1) physician and patient
these strategies to reduce personal anxiety [3].
factors, 2) diagnostic test and treatment characteristics 3) organi-
As important as understanding the patient’s beliefs are being
zational characteristics 4) medical information literacy and 5) time
open and honest with the patient regarding the holes that exist in
for interaction. Physicians and students differ in their tolerance to
the doctor’s position. The doctor should attempt to let the patient
uncertainty, which might alter their approach to patients with
know the relative success or failure of a recommended test or a
chronic undifferentiated illnesses or career choice. Further studies
 A.K. Ghosh, S. Joshi / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 14 (2020) 1529e1533 1533

Table 3
Consensus approach to managing medical uncertainty.

1) Provider to provider consensus

(i) Consensus building e Discuss case among physicians to sort out doubts or create committee of three or more specialists from same or different specialties to come to
common conclusions
2) Physician e Patient communication
i) Acknowledge the limits of medical knowledge
ii) Build trust with patient and encourage collaboration.
iii) Define the diagnosis and explain signs and symptoms and its relationship with the disease
iv) Communicate test results using a language easily understood by the patient
v) Guide the patient through all stages of decision making process
vi) Help negotiate plan to deal with situations requiring emergent action.
vii) Identify personal bias and resolve difference by consensus.
viii) Formulate adequate follow-up plan to assess change in clinical status

*Modified from references 33.

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