Viewpoint: Embracing uncertainty

Mrs Smith has come back to see me with a constellation of symptoms that, despite two referrals, we are no further forward to understanding. Her examination, bloods, and imaging are normal. She has no past history, rarely consults, and isn’t anxious. I call her in with trepidation, secretly hoping she will tell me the symptoms have vanished.

A career in general practice will offer plenty of uncertainty. Our accessibility means disease is seen earlier, and therefore symptoms may be vaguer. Being generalists we will encounter ‘unknown unknowns’ more often than our specialist colleagues and feel vulnerable about our knowledge. Then to make it really difficult, many symptoms are medically unexplained.

As medical science explains more, the unexplained becomes less satisfyingly acceptable, to doctor and patient.

Doctors in training often voice the challenge that uncertainty brings, while First5 GPs such as myself may well be realising that this challenge won’t go away. Uncertainly can get under your skin and cause self-doubt, resulting in anxiety or fear that may sadly result in burnout or overly defensive practice.

Workload is often cited as stressful, although I feel it is the proportion of uncertain workload that feels burdensome. If I feel confident and knowledgeable in my work, my energy and concentration feels boundless. If I don’t know, I falter and slow. This is of course natural as I need time to think. But the little red number on EMIS tells me that three people are looking at their watches in the waiting room. Running late stresses me and my mind is already wandering.

That said, my emotional response to not knowing will vary greatly. It will depend on how worried I am, how worried my patient is, my perception of error consequence, risk of litigation, and how often that morning I’ve already said the phrase, ‘I don’t know, but I don’t think it is serious.’ The scribbled ‘DEN list’ in front of me is growing ever longer.

A bit of anxiety drives us forward and is stimulating. Too much anxiety causes us to falter and feel overwhelmed. We should all be conscious of our internal anxiety level. In excess, anxiety impacts performance and restricts learning. If too comfortable we are failing to achieve our potential.

The trouble with fear is that it inhibits our learning, and so paradoxically impedes us from learning the very topic we need to know. We feel fear to keep us alive, bringing out a primeval fight or flight response, because entering into an academic debate with a woolly mammoth was presumably a natural selection disadvantage. And although a morning surgery can occasionally feel like a battle to survive, the environment has changed faster than our genes can adapt. Rock’s SCARF model illustrates that our instinctive reactions via the amygdala determine our cognitive state and readiness to learn.¹ This results in either an ‘approach’ or ‘avoid’ response. Notably, an avoid response is more easily generated than an approach response.

Was it curiosity or fear that made you read this far? Are you in learning mode or survival mode?

Questioning is a prerequisite of learning, and we tend to question when unsure or challenged. This was described by Mezirow as a ‘disorientating dilemma’.²

How fortunate we are to work in a career where we are constantly disorientated by dilemmas! The opportunity to learn and remain interested is the one thing I love so much about being a GP. We should learn to embrace uncertainty from the outset, allowing ourselves to be puzzled and reflective, and viewing it as a conduit to improving ourselves and the wider system. For fearing uncertainty will not make it go away, and it will suppress your own learning.

I urge you to consider how anxious you are made by uncertainty — reflecting if uncertainty is a benefit or burden to your learning potential, and to your emotional wellbeing.

• © British Journal of General Practice 2017