Dealing with uncertainty

I have recently become interested in the concept of uncertainty, particularly as it relates to remote clinical practice.  Uncertainty is a normal part of human existence, and very often it is an uncomfortable part.  People tend to try to minimise uncertainty, to reduce the discomfort it causes.  This occurs in a number of ways, and these have consequences for the safety and quality of clinical practice.

  • Avoidance is a common technique.  It involves manipulating the environment to eliminate or at least reduce the amount of uncertainty.  For example, a nurse who lacks confidence in dealing with children will avoid working in paediatrics, as this reduces the uncertainty he or she feels in this setting.  In a remote setting, this nurse may have no choice but to deal with children, and attempts to avoid doing so will have consequences for the health care team.
  • Denial is also common.  Uncertainty can be denied by simply ignoring the fact that it exists, and seeing all issues as black and white.  For example, if a patient is labelled as a drunk, there is no uncertainty about inconvenient differential diagnoses such as subarachnoid haemorrhage or hypoglycaemia.  The consequences for denial are obvious, and mostly stem from corrupting the evidence base for quality clinical practice.  If you ignore relevant alternatives, you do reduce uncertainty, but also increase the risk of being wrong.  Being wrong in clinical practice is typically detrimental to patients.
  • Logic can be used to try to reduce uncertainty.  Evidence is collected and weighed, and used to make a decision about a course of action.  The more comprehensive this process, the more valid the outcomes.  However, it requires time and effort, both of which can be in short supply at times.  There will always be another possibility that ‘should have been considered’, and the weighing of evidence is itself fraught with bias and uncertainty.  Logic and reasoning are valuable tools, and should certainly be used, but they do not eliminate uncertainty.  I’m not sure they even reduce it!
  • Dogma is another all-too-common approach to uncertainty.  For millenia, humans have sought explanations for things they do not understand, and religion has evolved to meet this need.  By attributing the unknown, and often also the known, to an omnipotent omnipresent diety, uncertainty is eliminated by stating that it is ‘God’s will’ or the ‘will of Allah’ or whatever.  Uncertainty then becomes evidence of a lack of faith, so the ‘faithful’ strenuously pretend to be certain of what they claim to believe.  Unfortunately, this does nothing to actually reduce uncertainty, and in fact makes it worse by pushing it underground.  In clinical practice, dogma is detrimental to safety and quality, as it absolves practitioners from responsibility for decisions – after all everything is ‘in God’s hands’.
  • Probably the least common approach to dealing with uncertainty is acceptance.  By accepting that uncertainty is normal and expected, practitioners can allow for the fact that they will make mistakes sometimes.  Reducing mistakes is part of professional development, but it is unreasonable to expect that they can be eliminated.  

I think the reality for most practitioners is that they use a bit of everything.  A dash of avoidance, a hint of denial, a cup of logic, a pinch of religion, and top up with acceptance.  The important thing is to be reflective and know what your coping mechanisms are.  This allows the practitioner to assess whether their approach contributes to or detracts from safety and quality.

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