Learning How to Deal With Uncertainty

Each time I call back a patient who sounds breathless, I wonder: Is it truly their asthma flaring or is it an undiagnosed pulmonary embolus? How long will I wait until I recommend a CT scan and convince the insurance company to cover it? Might my own anxiety about missing a dangerous but unlikely diagnosis cause the patient to be exposed to unnecessary chest radiation?

I’m guessing this internal monologue sounds familiar to most practicing physicians, not just early career pulmonologists like me. In situations with uncertainty, especially when there are no clinical guidelines, we have to find our own clinical thresholds and feel comfortable with them—or at least tolerate the discomfort. Although this skill may come with experience, I construe that it could be addressed more explicitly during training.

Last year, an Ideas & Opinions article in the Annals of Internal Medicine described a new approach for reducing diagnostic adverse events. The paradigm included 10 principles to ensure “care-full” diagnosis (1). Although this paradigm is specific to diagnosis, I believe it’s relevant to physicians in any specialty and particularly to physicians-in-training.

The authors describe the delicate balance of under- and overdiagnosis and the difficulty we have embracing the uncertainty that lies between. They suggest the following to avoid diagnostic error: 1) listen to patients, 2) spend adequate time with patients, 3) provide good continuity of care so that patients develop ongoing trust, and 4) consider watchful waiting as a strategy under appropriate circumstances. The simplicity seems so intuitive. How can these steps be missed in routine practice?

Well, the answer to that question is easy. Clinics and clinicians in the real world are busy. There are pager messages, telephone calls, voicemails, e-mails, text messages, result managers—the list goes on. It can be difficult to distinguish a cry for help from the ambient noise around you.

A paradigm like “care-full” diagnosis may help us not lose sight of our mission amid the daily chaos. I’d imagine the first 2 skills of listening and spending time with patients being mastered in medical school. Students should practice and feel confident communicating with patients and understanding them not only in the context of their illness, but also in the context of their family and community.

Later, when interns begin to care for patient panels of their own, they learn the cadence of outpatient medicine, which is a unique drumbeat. Between visits, patients may experience life events or observe us experiencing life events. These are important to acknowledge as the relationship unfolds.

Once the above foundation is laid, trainees can direct their attention to the skill of watchful waiting, especially in cases where they feel a high degree of clinical uncertainty. When I work with trainees on one of these cases, I try to address the following: What change in symptom would prompt us to bring this patient in for an office visit or a D-dimer? An emergency department visit or a chest CT? When should we reevaluate his/her symptoms over the phone? In person? What would we do if the patient requests invasive testing before the end of the watchful waiting period? On a weekend?

The skill of watchful waiting should not be underestimated, as it can require just as much discipline as learning a procedure and, like a procedure, requires adequate guidance at first. And I recognize that it’s hard to tolerate uncertainty even when there are clearly delineated clinical guidelines, let alone when there aren’t. In fellowship, I remember getting a pathology result back that was unexpectedly positive for lung cancer and wondering whether I should call all of my patients back in for early follow-up scans of their pulmonary nodules.

In situations without clear guidelines, I’ve been trying to frame the conversations with patients in terms of likelihoods and elicit patients’ preferences. And I’m finding that these discussions are going better as I’ve gained confidence to express my uncertainty—embracing it, rather than avoiding it. I haven’t felt that I’ve lost patients’ trust by simply saying, “In this particular case, I don’t know what the right answer is,” and then going on to discuss the options and my recommendation.

When I reflect on my time in training, residency and fellowship were busy years, but I feel my transition to attending has been easier because of the explicit conversations I had with preceptors about cases when we were uncertain. Integrating the “care-full” diagnosis paradigm into each level of medical education may help us recognize important milestones for learners. Mastering the skills may help us avoid diagnostic error in our daily outpatient practice both in training and after we transition to independent practice.

Reference

1. Schiff GD, Martin SA, Eidelman DH, et al. Ten principles for more conservative, care-full diagnosis. Ann Intern Med. 2018;169:643-5. [PMID: 30285046] doi:10.7326/M18-1468