Approaching Uncertainty in Medicine With a Growth Mindset

In baseball, a really good batting average is .333 — which means the batter hits the ball and gets to first base a third of the time. That also means they miss —they fail — two-thirds of the time. Medical providers are expected to get things right 100% of the time,” says Michael Patrick, MD, emergency medicine and urgent care attending physician at Nationwide Children’s Hospital and host of PediaCast and PediaCast CME.

The idea that medical providers are expected to “get it right” 100% of the time leaves no room for uncertainty — but uncertainty in medicine does exist.

In a recent episode of PediaCast CME, a group of experts explored uncertainty in medicine and how accepting uncertainty can help everyone — patients, clinicians and trainees – move forward in ways that lead to better patient safety, increased job satisfaction and decreased burnout.

Types of Uncertainty

Broadly speaking, uncertainty is the “actual or perceived inability of a clinician to identify causes of symptoms, make a diagnosis, offer prognosis and outline the best course of treatment,” says Anna Kerr, PhD, a health communication researcher at Ohio University.

Types of uncertainty fall into three main categories: technical, personal and conceptual.

Technical uncertainty is also sometimes called data-related uncertainty. Here, a clinician lacks knowledge, skills or certain data needed to make a diagnosis or perform a procedure. This type of uncertainty is common among trainees, says Claire Stewart, MD, critical care physician and associate program director for the Pediatric Critical Care Medicine Fellowship at Nationwide Children’s. For example, they may feel uncertain about their ability to perform a specific procedure.

Personal uncertainty is also called relationship-related uncertainty. Clinicians who don’t know their patient’s (or patient family’s) values, wishes or expectations can experience this type of uncertainty. Dr. Stewart says, in the pediatric intensive care unit (PICU), clinicians may feel personal uncertainty when a patient is nearing the end of their life — not knowing the family’s values or desires for continued treatments creates uncertainty. If a clinician is unwilling to confront personal uncertainty and ask families about their wishes, shared decision-making becomes nearly impossible.

Conceptual uncertainty is application-related uncertainty. In this case, clinicians are unable to apply concrete criteria. They have knowledge and skills, but for some reason, they are not able to apply them to a specific patient or situation. This could be related to a patient’s symptoms not fitting into a diagnosis or a typical course of treatment not working for an unknown reason.

Harms of Not Acknowledging Uncertainty

“If you don’t openly discuss uncertainty in health care teams, it’s to the detriment of patient care,” says Charee Thompson, PhD, associate professor of Communication and Biomedical and Translational Science at the University of Illinois Urbana-Champaign.

On a population health level, uncertainty can cause harm if clinicians order unnecessary tests out of fear of missing something. Unnecessary tests may mean additional blood draws, which carry physical risks for children. Unnecessary tests and unwarranted referrals to specialists also increase the financial and time burden of care for patients and their families, explains Dr. Thompson.

“In the case of rare or undiagnosed diseases, a clinician’s inability to sit with the discomfort of uncertainty can lead to premature, incorrect diagnoses,” says Dr. Kerr.

Uncertainty as Opportunity

But uncertainty is not necessarily a bad thing. It can be fuel for collaboration, research, innovation and discovery. Even better — normalizing uncertainty leads to increased trust.

“When uncertainty is addressed, it can ultimately improve patient safety and care. But for positive outcomes, uncertainty needs to be discussed openly and lead to growth,” says Dr. Kerr

Alex Rakowsky, MD, medical director of the Healthy Kids Service Line for Partners For Kids®, primary care clinician at Nationwide Children’s and associate professor of Pediatrics at The Ohio State University, likes to share this example of how seeing uncertainty as an opportunity led to an unexpected learning.

In a primary care office, physicians were noticing higher lead levels among one-year-olds of Afghani immigrants. They started testing for lead earlier and discovered that levels were raised from infancy. After interviewing families and asking about possible sources of lead, Dr. Rakowsky reached out to the toxicology team at Nationwide Children’s. Working together, they discovered the source of lead was in body paint (kohl) imported from Afghanistan, which is traditionally used around babies’ eyes. The clinicians shared this information with the families, and a local store began selling lead-free kohl.

This open approach led to collaboration and contributed to the trusting patient-provider relationship among a potentially vulnerable population.

Addressing uncertainty also helps build trust among trainees and teachers.

Trainees have been ingrained to find “the” correct answer their entire academic careers, says Dr. Stewart. Then they come into the clinic and find out that’s not how things work in the real world.

It’s important for attendings to model how to address uncertainty among themselves, with trainees and with patients, she adds. “We must show that it’s not just expressing uncertainty but identifying what we are going to do about it. We can’t just leave it at ‘I don’t know.’”

Unaddressed uncertainty among trainees has been shown to contribute to burnout and depression, according to a study published in Medical Teacher. Attendings and mentors play an important role in equipping the next generation of clinicians to handle uncertainty and approach it with a growth mindset.

“Communication is a science,” says Dr. Thompson. “And so we have tools that we can teach that are evidence based in how you can better communicate, because research tells us over and over that suppressing uncertainty is harmful. So the question becomes: how can we communicate uncertainty?”

Drs. Thompson, Kerr, Rakowsky and Stewart are part of a group working to develop a curriculum for medical trainees to do exactly that. Their initial work has been published in Hospital Pediatrics.

This article also appears in the Fall/Winter 2024 print issue. Download the full issue.

References:

1. Simpkin AL, Schwartzstein RM. Tolerating uncertainty – the next medical revolution? New England Journal of Medicine. 2016;375:1713-1715.
2. Gheihman G, Johnson M, Simpkin AL. Twelve tips for thriving in the face of clinical uncertainty. Medical Teacher. 2020;42(5):493-499.
3. Kerr AM, Thompson CM, Stewart CA, Rakowsky A. ‘I want them to still trust me with their child’s care’: A longitudinal study of pediatric residents’ reactions to and communication with parents about medical uncertainty across residency. Health Communication. 2021:38(5): 1054–1064.
4. Dahm MR, Crock C. Understanding and communicating uncertainty in achieving diagnostic excellence. JAMA. 2022;22;327(12):1127-1128.
5. Kerr AM, Thompson CM, Stewart CA, Rakowsky A. Residents’ Communication With Attendings About Uncertainty: A Single-Site Longitudinal Survey. Hospital Pediatrics. Published online September 5, 2024.

Image credits: Nationwide Children’s (header, Rakowsky and Stewart); Kerr (portrait); Thompson (portrait)