Physician expressions of uncertainty during patient encounters

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Abstract

Uncertainty is inherent in clinical medicine and may contribute to variability in physician practice patterns, patient satisfaction, and exchange of information. However, research on physician disclosure of uncertainty to patients is sparse. We measured the frequency of physician expressions of uncertainty to patients using audiotapes of visits to 43 physicians by 216 continuity patients in a university-affiliated general medicine clinic. We also analyzed the audiotapes using Roter Interaction Analysis. Physicians completed Gerrity’s Physicians’ Reaction to Uncertainty scale and patients completed the Kranz Health Opinion Survey and a standardized satisfaction questionnaire. Physicians made verbal expressions of uncertainty in 71% of clinic visits. Physicians with greater self-rated reluctance to disclose uncertainty to patients made fewer expressions. Physicians who made more uncertainty expressions also used more positive talk and partnership building, and gave more information to patients. Physicians also expressed more uncertainty to patients with more education, greater desire for information, and more questions. Physician uncertainty expressions were associated with greater patient satisfaction, but not independently of other physician verbal behaviors that were also associated with satisfaction.

Introduction

Uncertainty is inherent in medical practice [1], [2], [3], [4], [5], [6]. Uncertainty may contribute to variability in physician practice patterns including excessive use of diagnostic tests, treatments and other resources [7], [8], [9]. It also contributes to patient and physician anxiety, dissatisfaction, and regret [10], [11], [12], [13], [14]. Uncertainty complicates quality of care standards, malpractice judgments, informed consent, and resource allocation [6], [7], [15], [16], [17]. The need to cope with uncertainty is likely to increase as medical knowledge expands [6], [18], [19].

Research on physician disclosure of uncertainty to patients is sparse. Katz wrote that physicians habitually suppress and deny uncertainty with patients in order to take action in difficult circumstances and to maintain patient confidence [13]. Quill and Suchman described an “illusion of certainty” in medicine and outlined steps for sharing uncertainty with patients [20]. Lynn described disclosure of uncertainty to a patient, noting that the process can generate hope and opportunity, and well as worry and concern [21]. Hewson et al. described steps for “strategic medical management” of uncertain and complex medical problems, including acknowledging and discussing uncertainty [22]. Physicians’ use of the steps were examined in encounters with simulated patients but the frequency of uncertainty statements was not reported.

Physician expressions of uncertainty to patients are consistent with an increasingly accepted model of care that values information exchange and shared decision-making over physician certainty and control [23], [24]. However, patients can be dissatisfied when physicians are uncertain about information. Johnson et al. [10] found that patients watching a videotape of a simulated clinic visit were most satisfied when the physician disclosed no uncertainty and least satisfied when the physician disclosed but ignored uncertainty, or consulted a resource in the patient’s presence. Patients’ dissatisfaction was more closely related to their perception of physician uncertainty than to actual physician actions, and was greater when they expected physicians to “always know the answers.”

Our goal in this study was to identify physician expressions of uncertainty during actual clinic visits and to examine their associations with physicians’ and patients’ characteristics and communication behaviors.

Section snippets

Data sources and subjects

The study was conducted in the General Medicine Clinic of the Portland, Oregon Veterans Affairs (VA) Medical Center and was approved by the hospital’s Human Subjects Committee. We used audiotapes of scheduled continuity visits by patients to their physicians. The audiotapes were made during a prior study of physician–patient communication [25]. Patients were eligible for the study if they had at least one chronic illness requiring medication and had seen the study physician in a continuity

Data analysis

Some data were collected at the level of the visit and patient (e.g. patient and physician utterances, patient satisfaction and desire for information) and some at the physician level (physicians’ reaction to uncertainty). We wanted to describe physicians’ use of uncertainty statements and examine its association with their patients’ satisfaction, but we could not assume that visits by different patients to the same physician were independent observations. Therefore, we averaged the data

Results

Physicians made direct expressions of uncertainty in 154 (71%) of visits. There were a total of 475 expressions in these 154 visits, with a range from 0 to 14 per visit (mean=2.19, S.D.=2.52). Most of the expressions were about diagnosis or treatment. Physicians differed from each other in the mean number of uncertainty expressions they used across all their visits. The mean number of uncertainty expressions per physician ranged from 0 to 4.20 (F(42,173)=1.459, p=0.049). However, there were no

Discussion

Physicians made verbal expressions of uncertainty in 71% of clinic visits. Uncertainty expressions were associated with patient satisfaction, but not independent of other physician verbal behaviors (positive talk, partnership building, and information-giving) that others likewise have found to be correlated with patient satisfaction [24], [34]. Physician uncertainty expressions also were positively associated with patient characteristics such as desire for information, seeking and giving

Conclusions and practice implications

Our findings have direct applications to clinical teaching and practice. Medical education has been described as “training for certainty” with overemphasis on unambiguous facts, solvable problems, and correct answers [37], [38], [39]. As trainees take on more clinical responsibility, their efforts are aimed at controlling uncertainty [40]. Experienced practitioners may find ways to communicate and collaborate more effectively with patients when uncertainty exists [20], [21]. In our study, group

Acknowledgements

This work was supported by a grant from the Zlinkoff Foundation for Medical Research and Education and by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Program, Portland Veterans Affairs Medical Center

References (41)

  • J.T. Lynn

    On medical uncertainty

    Am J Med

    (1994)
  • M.A. Nakao et al.

    Numbers are better than words: Verbal specifications of frequency have no place in medicine

    Am J Med

    (1983)
  • P. Atkinson

    Training for certainty

    Soc Sci Med

    (1984)
  • S. Toulmin

    On the nature of the physician’s understanding

    J Med Philos.

    (1976)
  • R.C. Fox

    The evolution of medical uncertainty

    Milbank Memorial Fund Quarterly

    (1980)
  • H.J. Bursztajn et al.

    Medical choices, medical chances: how patients, families, and physicians can cope with uncertainty

    (1990)
  • M.S. Gerrity

    Conceptual models for understanding and measuring physicians’ reactions to uncertainty

  • Beresford E. Uncertainty and the shaping of medical decisions. Hastings Center Report....
  • D.M. Eddy

    Variations in physician practice: The role of uncertainty

    Health Affairs

    (1984)
  • J.P. Kassirer

    Our stubborn quest for diagnostic certainty: A cause of excessive testing

    N Engl J Med.

    (1989)
  • F. Davidoff et al.

    Changing test ordering behavior: A randomized controlled trial comparing probabilistic reasoning with cost-containment education

    Med Care.

    (1989)
  • C.G. Johnson et al.

    Does physician uncertainty affect patient satisfaction?

    J Gen Intern Med.

    (1988)
  • S.P. Curley et al.

    An investigation of patients’ reactions to therapeutic uncertainty

    Med Decis Making

    (1989)
  • C.L. Bosk

    Occupational rituals in patient management

    N Engl J Med.

    (1980)
  • J. Katz

    Why doctors don’t disclose uncertainty

    The Hastings Center Report

    (1984)
  • J.C. Hershey et al.

    Clinical reasoning and cognitive processes

    Med Decis Making

    (1987)
  • D.M. Mirvis et al.

    Managed care, managing uncertainty. Arch Intern Med. 1997;157:385–388

    J Med Philos.

    (1976)
  • D.M. Eddy et al.

    The quality of medical evidence: Implications for quality of care

    Health Affairs

    (1988)
  • T.G. Gutheil et al.

    Malpractice prevention through sharing of uncertainty: Informed consent and the therapeutic alliance

    N Engl J Med.

    (1984)
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    Portions of this work were presented at the 17th and 18th Annual Meetings of the Society of General Internal Medicine, 1994 (Washington, D.C.) and 1995 (San Diego, CA).

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