Physician expressions of uncertainty during patient encounters☆
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)
On medical uncertainty
Am J Med
(1994)- et al.
Numbers are better than words: Verbal specifications of frequency have no place in medicine
Am J Med
(1983) Training for certainty
Soc Sci Med
(1984)On the nature of the physician’s understanding
J Med Philos.
(1976)The evolution of medical uncertainty
Milbank Memorial Fund Quarterly
(1980)- et al.
Medical choices, medical chances: how patients, families, and physicians can cope with uncertainty
(1990) Conceptual models for understanding and measuring physicians’ reactions to uncertainty
- Beresford E. Uncertainty and the shaping of medical decisions. Hastings Center Report....
Variations in physician practice: The role of uncertainty
Health Affairs
(1984)
Our stubborn quest for diagnostic certainty: A cause of excessive testing
N Engl J Med.
Changing test ordering behavior: A randomized controlled trial comparing probabilistic reasoning with cost-containment education
Med Care.
Does physician uncertainty affect patient satisfaction?
J Gen Intern Med.
An investigation of patients’ reactions to therapeutic uncertainty
Med Decis Making
Occupational rituals in patient management
N Engl J Med.
Why doctors don’t disclose uncertainty
The Hastings Center Report
Clinical reasoning and cognitive processes
Med Decis Making
Managed care, managing uncertainty. Arch Intern Med. 1997;157:385–388
J Med Philos.
The quality of medical evidence: Implications for quality of care
Health Affairs
Malpractice prevention through sharing of uncertainty: Informed consent and the therapeutic alliance
N Engl J Med.
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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).