Whether you like to admit it or not uncertainty exists in everything including ALL aspects of healthcare. There is uncertainty in our assessments, diagnoses, prognoses, and of course our treatments. Being uncertain in healthcare occurs a lot, yet conversely, not many are willing to admit it or talk about it.
And that’s perfectly natural as when we are faced with any uncertainty it makes us feel deeply uncomfortable, awkward, and foolish. Instinctively we avoid, ignore, or deny situations of uncertainty, and this is becoming the norm in our over-confident, unabashed, ego-driven society!
Being uncertain goes against our human nature that we have evolved to be sure in our thinking and decisions which is essential for our survival. Humans, therefore, tend to trust and gravitate towards those who are certain, all knowing, and have answers, over those who don’t. A perfect example of this is on social media.
You only have to look at healthcare professionals with 1000’s of followers to see that their popularity is formed and based most of the time on certainty. They will often display conviction that they have the truth, answers, and knowledge to help those in need.
Rarely will you see a popular social media healthcare ‘celebrity’ express doubt or uncertainty. This needs to change! We all need to acknowledge, admit, and accept uncertainty better, but this ain’t easy, in fact, it’s really bloody difficult!
I don’t know things!
I hate not knowing things, it’s one of the reasons why I read so much in an attempt to learn more and understand things better. But the cruel, cold, heartless paradox of knowledge is the more you learn the more you realise how little you actually know, Dunning and Kruger have a lot to answer for!
I also hate being in a position of having to admit not knowing what to do, or how best to proceed, or more commonly what to say to a patient when they ask me whats the cause of their pain. But this happens a lot in my work. A helluva lot!!!
If you are a well-read evidenced-based healthcare professional, you will realise that our ability to diagnose the cause of someone’s pain is notoriously difficult and uncertain due to many of our tests and procedures being riddled with low specificity, poor reliability, and even worse validity.
This doesn’t mean we give up or become lazy and don’t bother trying to diagnose a patients pain. It just means we realise and recognise that AFTER we have done a full and thorough assessment to the best of our ability, we are often able to rule out anything serious or sinister, but are often left unsure why someone has pain or what is causing it.
Being uncertain in front of patients used to make me feel awkward, foolish and stupid, and it still does at times. This used to make me feel annoyed, frustrated, even angry and it still does at times. However, slowly, steadily, gradually I have learnt to tolerate the uncertainty in my knowledge and my work, and I now think I am getting better at expressing it and passing it onto my patients. But it still isn’t easy!
One of my favourite researchers in uncertainty who has helped me deal with it better is Dr Arabella Simpkin. You may have read her excellent editorial in the New England Journal of Medicine back in 2016 here. If not please go read it now, it is a wonderful piece of writing that summarises and reflects all the issues I am trying to make.
Tips for uncertainty
Dr Simkin has also co-authored this paper here recently published that attempts to give all healthcare professionals ‘tips for thriving in the face of clinical uncertainty’. Again this is a really insightful, useful, and topical paper and I would urge you all to read it in full. I have summarised the key tips they suggest for thriving with uncertainty in healthcare below.
No 1: Be prepared
Try to identify as many areas of uncertainty that you have. Things such as particular pathologies, patients, or procedures that you feel unsure or unclear about. Then to the best of your ability try to reduce this by reading, practising, asking colleagues for assistance.
Next prepare yourself for how you will act and react when confronted with not knowing something in front of a patient. Think about what you will say, and how you will say it, and plan what you will do and who can assist you.
No 2: Recognise the type of uncertainty
Is the uncertainty a knowable unknown, or a truly unknown unknown? Diagnosing the type of uncertainty can help you clarify and plan a path forward to suggest appropriate management strategies. The three classifications of uncertainty are…
- Sources; such as issues with probability, ambiguity, and complexity
- Issues; such as lack of knowledge, practical experience, or personal skills
- Locus: who is the uncertainty with, the clinician or the patient
No 3: Be aware of biases
The desire for certainty leaves all of us open to cognitive biases, the main ones to be aware of are…
- Availability Bias; Making a diagnosis based on information easily remembered and recalled rather than what’s more likely and probable.
- Anchoring Bias: Settling on a diagnosis early on in the assessment and not amending it when new information becomes available.
- Representativeness: Comparing a case to previous typical cases via pattern recognition but ignoring other atypical features present.
No 4: Have a plan
Ensure you have a ‘safety net’ for all cases of uncertainty, don’t just ignore them or wash your hands of them. Building a mechanism of follow up into your practice gives clinicians a chance to correct their treatment plan as time and the ‘illness’ evolves if a wrong decision was made in the early stages when limited information was available.
No 5: Have a network
Surround yourself with colleagues and peers who you feel comfortable and safe in expressing uncertainty and doubt with. Use them as a soundboard to share ideas and gage opinion on what to do and how to proceed.
However, try not to only limit this group to ‘your tribe’ or speciality. Use and employ colleagues from other areas and disciplines of healthcare for a wider more varied view.
No 6: Be a role model
Talking openly about uncertainty helps normalise it and can help set a culture that embraces uncertainty. Never be afraid to say ‘I don’t know’. It can help others around you gain the confidence to do the same and help others realise that sharing uncertainty is what good healthcare culture should be.
No 7: Promote curiosity
Curiosity is a basic element of understanding and a key motivator for learning. Appreciate and reward others for expressing curiosity and make time to discuss and answer questions. Use ‘how’ and ‘why’ questions rather than ‘what’ and ‘when’, and consider using the more flexible word ‘hypothesis’ more than the fixed and rigid ‘diagnosis’
No 8: Discuss uncertainty openly with patients
This, in my opinion, is the most important, and the most the challenging aspect of uncertainty in healthcare. However, the question is not whether we should share uncertainty with our patients but how best to do it without losing their confidence or causing them anxiety.
Although we all worry about the negative effects of admitting uncertainty to patients there is research that suggests expressions of uncertainty can lead to stronger patient-clinician relationships (ref). When clinicians are open and honest in response to patients questions using phrases such as ‘i don’t know‘ or ‘its not clear’ there is often higher patient engagement and satisfaction (ref).
Summary
In my experience, no patient likes to be fobbed off or bull shitted too and often they know when this is being done. So when asked a question that you can not, or do not know how to answer, do not fear saying ‘I don’t know’. Expressing uncertainty to your patients doesn’t make you appear ignorant, inexperienced, or foolish. If anything being too confident and certain can make you appear arrogant, aloof, and an arsehole.
I have found that once you get over your own inadequacy issues and inferiority complexes and start to say ‘I don’t know’ more often, it does get easier. I have also found the key to success in expressing uncertainty with patients is to do it compassionately, empathetically, but most important of all, do it confidently.
I am often uncertain as to exactly what, where, or why someone has pain, but I am often confident that there is nothing serious or sinister and that they can get a good outcome with time, rehab, lifestyle modifications and that I will do my best to help, support, and encourage them to achieve this.
So in summary, as a healthcare professional learn to be confidently uncertain in an ever-increasingly certain world!
As always thanks for reading
Adam (I don’t know things) Meakins
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In your closing, you say, “I have found that once you get over your own inadequacy issues and inferiority complexes and start to say ‘I don’t know’ more often, it does get easier.” While that sounds sensible, it seems that the continued refusal by the PT profession to explore the psychological and sociological dimensions of health keeps it rooted in its own Self ignorance. Your words presume insight, an assumption worth exploring.
Physiotherapy is a profession that has yet to gain independence from its biomedical parentage, still living at home in their basement, figuratively speaking. The profession does not have a mature, independent voice nor an identity guided by reflective thought that has differentiated it from its medical parents. Physio still craves the attention and validation of its parents who to it, represent the very certainty you allude to. It acts in self-aggrandizing ways to create and curate a facade of perfectionism for such purpose of feeling more secure. By very definition this is narcissistic at a professional/cultural level. To expect as your quotation seems to imply that somehow the profession will or should just “get over” it’s issues as fundamental as they are, seems awfully naive and unexplored.
“Which of us can resist the temptation of being thought indispensable?”
― Margaret Atwood, The Penelopiad
Hi Billie
I agree with what you say. I do find the physiotherapy profession and most of those who work within it behave subserviently to our medical and surgical colleagues. This is historic and hierarchical and wont be changed with a blog or any one individual. This needs a shift in culture and societal behaviour, as well as at the educational systems of both physio and medicine.
However, I do think that as individuals we can all try a little to ‘get over’ our inadequacy and inferiority issues one by one, day by day and start making change where we can the easiest, with ourselves.
All the best
Adam
To your reply, I wholeheartedly agree! Healthy change happens because individuals decide to, not because they are told to. I hope more physios reach a point where they have to press pause and decide that there must be a better way worth looking for.
Adam, thank you for writing this post. I spend an inordinate amount of time wondering what is wrong with me because everyone else seems to be so sure of what they are doing and I’m not! I’d feel much better if people would just be more open to ambiguity and honest. I remember being told as a student, that if I didn’t know the answer I couldn’t say ‘I don’t know’, I had to come up with SOMETHING. I could never work out why being honest was inferior to bullshitting! On balance, I value the truth more, but it is hard to go down the line of being a bit vague when everything about the culture around you is telling you to be firm and stick to it, or when the patient is looking to you for answers and it feels more productive to weave a narrative around a diagnosis so that they follow a treatment plan….. More discussions about this please!
Thanks, Martin, and I agree this is a topic that needs to be discussed more. I think the biggest barrier of saying I don’t know is appearing ignorant or perhaps allowing ineptitude and laziness to creep into physios assessments and treatments and this does need to be addressed. It’s very easy for a physio to just say I don’t know or this isn’t my issue or problem and wash their hands of patients with unclear or uncertain symptoms.
Thank you Adam, this is a timely topic for me. I feel at times that I am failing my client when I don’t get everybody ‘fixed’. (sounds like neutering now that I think about it) I have ended up beating myself up and criticising myself, my teachers and anyone else in range which just ended up with me being unhappy and suffering as well as people around me and the patient well they just did not return. I am more forgiving of myself and the people who come in with pain because; they don’t know, and I find I get better results when we work collaboratively rather than didactically. I appreciate your courage to talk about this, and I look forward to your next post