To do or not to do: Teaching the skill of deciding what to do in the face of uncertainty

If to some problems we can attach a formal diagnosis, that’s a bonus: what we must always do for every problem diagnosed or not, is decide what to do about it.

– Roger Neighbour,
The inner consultation¹

The management of undifferentiated presentations is a defining feature of general practice.² A general practitioner (GP) is expected to distinguish serious disease from the myriad presentations that ‘walk through the door’ while efficiently managing health resources. Not surprisingly, a patient’s journey in primary care frequently concludes without a formal diagnosis being made.³ Deciding what to do in the face of uncertainty is the ‘art’ or ‘special technique’ of general practice.^1,4

The skill of managing uncertainty is difficult to define. There is no universal definition of clinical uncertainty⁵ and little empirical evidence in the literature to deconstruct the skill of managing uncertainty into constituent behaviours.⁶ The assessment rubric used in the final RACGP Fellowship assessment has only three criteria for the competency of managing uncertainty, including the self-evident descriptor that it is the ability to recognise ‘when to act and when to defer doing so’.⁷ In this regard, the management of uncertainty, like professionalism, is a ‘soft’ skill elusively defined as being known when it is seen.

Despite the skill of management of uncertainty being difficult to define and assess, there is extensive literature devoted to describing how it is best learnt and taught.

Aim

In this article, the current approaches described in the literature for how a GP supervisor should teach their registrar the management of uncertainty are summarised. A novel method developed by the author from his personal experience as a GP supervisor is then introduced.

Supervisor approaches to teaching the management of uncertainty

A summary of these approaches is provided in Box 1.

Make explicit the different paradigm operating in primary care

For registrars, the transition from working in hospitals to working in general practice involves a fundamental shift in their approach to uncertainty. They are asked to adopt a patient-centred approach in an environment where serious disease is unlikely and a ‘wait-and-see’ strategy is feasible. This is in stark contrast to the investigation-based pursuit of immediate diagnostic certainty in hospital medicine. Without an appreciation of the different paradigm operating in primary care, a registrar might view the general practice approach to the management of undifferentiated presentations as ‘full of shortcuts’ and ‘inferior medicine’,^8,9 and consequently disregard their supervisor’s recommendations.¹⁰

To overcome this risk, a supervisor should make explicit the assumptions underlying primary care decisions, and reveal how the paradigms of primary and secondary care are philosophically and practically different.¹¹ One approach to the management of uncertainty should not be seen as superior to the other, but rather that each is appropriate for the context.¹²

A readily available opportunity for a supervisor to demonstrate this difference is when comparing the approaches to test ordering. In hospital care, the pre-test probability of disease is higher, and tests might appropriately be ordered to rule out a diagnosis. In primary care, when the pre-test probability of disease is low, adopting the same approach is unwise practice.^13–15 A positive result is more likely to be a false positive. The patient is also exposed to the risk of the test coincidentally uncovering abnormalities that ultimately turn out to be meaningless, so-called ‘incidentalomas’. Compared to these harms of test ordering in a low pre-test probability environment, the benefit of confirming the absence of an already unlikely diagnosis is minimal. Discussing the negative consequences of a false-positive result for the patient, or the wasteful and often distressing investigative cascade that follows a coincidental result, can be a salient lesson for the registrar.

Normalise uncertainty

Despite uncertainty being a common feature of clinical practice, the culture of medicine is to place value on certainty and focus on how to reduce uncertainty rather than how to tolerate or manage it.⁵ In this environment it is unsurprising that anxiety about clinical uncertainty has been linked to GP registrar burnout¹⁶ and increased healthcare costs.¹⁷ Fear of litigation can lead to overcautious prescribing, investigations and referrals.¹⁸ Supervisors should normalise the presence of uncertainty and view discussions of the registrar’s uncertain cases as an opportunity to help them develop a sustainable model of practice. Collegiate reflection on challenging cases has been found to help primary care physicians deal with, and learn from, managing uncertainty.¹⁹

It can be difficult for registrars to share their uncertainties, particularly if they perceive this will cause them to lose credibility in the supervisor’s eyes. To overcome this registrar reticence, supervisors are encouraged to expose their own uncertainties first. Such normalisation of uncertainty or ‘intellectual candour’ encourages the registrar to reciprocate.²⁰ Furthermore, there is an opportunity in such reflections to demonstrate that uncertainty in primary care does not arise from biomedical considerations alone. A GP is as likely to be uncertain about decisions due to an appreciation of psychosocial and cultural factors impacting on choices in the patient’s care.^21,22

Demonstrate shared decision making

Consistent with the patient-centred ethos of primary care, GPs often manage uncertainty by sharing the decision with the patient. A shared decision is made after uncovering the patient’s ideas, concerns and expectations, and the doctor revealing the clinical reasoning and the management options they are considering.²³

GP supervisors frequently have an opportunity to demonstrate the skill of shared decision making when called by their registrar into a consultation to help manage a patient. The ‘thinking aloud’ strategy recommended to avoid undermining the patient–registrar relationship in ad hoc supervisory interactions²⁴ is also the stage of the ‘doctor revealing clinical reasoning and management options’ in shared decision making. Frequently the patient feels invited to share their own thoughts at this time, and a shared decision naturally follows. Even when a diagnosis cannot be made, there might be patient concerns uncovered by thinking aloud that a GP can confidently rule out. This ‘saying what it is not’ technique has been described as having ‘uncertainty without being uncertain’²⁵ and is a useful approach a GP registrar might not have encountered previously.

Shared decision making is not universally applicable when managing uncertainty. It is not always possible to reach an agreed decision and registrars need support in learning how to manage unreasonable or unsafe patient expectations.²⁶ A patient might not be willing to share decision-making responsibility with the clinician either because they have not yet built trust in the clinician’s capacity or because they wish the clinician to take full responsibility.²⁷ In teaching sessions, the thoughts and emotions involved in the choice of whether to adopt a shared decision-making approach are fertile topics for discussion.

Encourage safety netting and follow‑up

Safety netting is a well-known skill used at the conclusion of a consultation to manage uncertainty and ensure patient safety.¹ When discussing cases, a supervisor should question their registrar about intended safety net conversations.

The arrangement of follow-up consultations is another method used to reduce risk when managing uncertainty. Registrars are reported to frequently be unfamiliar with the practice of follow-up consultations.²⁸ The registrar might be concerned about the inconvenience or cost impost to the patient of a review appointment. Supervisors should be alert to this risk and normalise the practice of follow-up, particularly in the face of uncertainty. Discussions about the appropriate use of telehealth or telephone consultations and billing strategies for follow-up appointments might ameliorate a registrar’s reluctance to organise follow-up.

Explore uncertainty by considering diagnostic options

Registrars frequently bring problem cases to discuss during teaching sessions.²⁹ The management of uncertain situations can be explored using Murtagh’s diagnostic model (Table 1).³⁰ The questions in this model about not-to-be-missed and frequently missed diagnoses are designed to promote safe management of uncertainty. The answers can also be used to inform safety netting instructions.

The use of this model allows the supervisor to share their ‘cautionary tales’, ‘illness scripts’, ‘management scripts’ and ‘key features’ that aid the development of clinical reasoning and safe patient care.³¹

Explore uncertainty by considering management options

Frequently in primary care, it is not possible to achieve a diagnosis.¹ Management decisions still must be made; they are not beholden to a diagnosis. The author has found the use of a strategy – dubbed the 3Rs of uncertainty – that considers the management options when confronted with uncertainty to be a method that complements Murtagh’s diagnostic model. As presented in Table 2, a supervisor can consider the following three options with a registrar to manage uncertainty: review; refer; and Rx (treat).