Navigating Uncertainty in Clinical Practice: A Structured Approach

Abstract

The practice of clinical medicine is imbued with uncertainty. The ways in which clinicians and patients think about, communicate about, and act within situations of heightened uncertainty can have significant implications for the therapeutic alliance and for the trajectory and outcomes of clinical care. Despite this, there is limited guidance about the best methods for physicians to recognize, acknowledge, communicate about, and manage uncertainty in clinical settings. In this paper, we propose a structured approach for discussing and managing uncertainty within the context of a clinician-patient relationship. The approach involves four steps: Recognize, Acknowledge, Partner, and Seek Support (i.e., the RAPS framework). The approach is guided by existing literature on uncertainty as well as our own experience as clinicians working at different stages of career. We define each component of the approach and present sample language and actions for how to implement it in practice. Our aim is to empower clinicians to regard situations of high uncertainty as an opportunity to deepen the therapeutic alliance with the patient, and simultaneously to grow and learn as practitioners.

INTRODUCTION

Uncertainty is intrinsic to the practice of clinical medicine and relates to all components of clinical care including diagnosis, management, outcomes, relationship-building, and affective experiences. Conversations between physicians and patients in the presence of uncertainty and about uncertainty can have implications for rapport and trust in the physician–patient relationship and for the trajectory of clinical care.^1,2 While there has been recognition of the importance of factoring uncertainty into medical decision-making and clinical care,³ limited specific guidance exists surrounding the best methods for physicians to communicate about and manage uncertainty in partnership with patients.² While recent guidance exists regarding how to communicate about uncertainty with patients,² and about how to understand uncertainty as a challenge in communication,^2,4,5 a practical approach to managing uncertainty that can be easily integrated into clinical practice and that goes beyond the act of communication has not yet been described. Here, we propose a structured approach, guided by existing literature and our experiences as clinicians, for navigating uncertainty in clinical care. This tool encompasses the following four steps: Recognize, Acknowledge, Partner, and Seek Support, abbreviated as the RAPS framework.

BACKGROUND

The characterization of uncertainty in clinical medicine has evolved in the literature over time. In 1957, Renée Fox described uncertainty in domains focused on practitioners, centering on a physician’s limits in the mastery of medical knowledge and the broader limitations of medical science.⁶ Subsequently, evolving principles of bioethics were introduced into the understanding of clinical uncertainty.⁷ Beresford’s 1991 model, for example, incorporated a patient’s goals for treatment and the potential inability of a clinician to understand these preferences as another possible dimension of uncertainty.⁷ Beresford’s model emphasized that certain origins of uncertainty are beyond the realm of the practitioner. Several additional sources of uncertainty have been identified and incorporated into present-day models, including patient care goals, the concept of probabilistic reasoning, cognitive and implicit biases, and the emotions of patients and clinicians.^7–13

Situations of heightened clinical uncertainty can present challenges for the patient and their family and community, for the physician, and for the relationships between these entities. The responses to uncertainty have been characterized to encompass the cognitive, emotional, and behavioral domains and in each of these domains, responses can be either negative or positive. That is, uncertainty can provoke anxiety, denial, aversion, or inaction. However, it can also engender motivation, curiosity, learning, and hope.¹⁴

Existing literature has also explored the implications of uncertainty tolerance on physician wellbeing and clinical care. Physicians who report higher levels of anxiety in the face of clinical uncertainty have lower levels of job satisfaction, higher likelihood of depression during training, and higher rates of burnout, with these effects particularly pronounced in trainees.^15–17 However, current measures of uncertainty tolerance and the characterization of negative emotional experiences brought on by uncertainty may not fully capture clinician adaptive responses to uncertainty.¹⁸ Responses to uncertainty may also affect resource utilization. In one study, primary care physicians with a lower uncertainty tolerance had higher rates of resource utilization than their peers.¹⁹ A more recent study resulted in a seemingly contrasting finding: primary care physicians with a lower uncertainty tolerance were less likely to order basic laboratory studies.²⁰ Given the clinical and workforce implications of uncertainty tolerance, it is important for physicians to effectively engage with uncertainty. Indeed, the ability to acknowledge and manage uncertainty has been called “The Next Medical Revolution,”³ and the Accreditation Council for Graduate Medical Education includes integration of knowledge and evidence in the face of uncertainty as a core educational competency in internal medicine training.²¹

Despite its widely recognized importance, there are barriers to physicians and patients navigating uncertainty effectively in clinical spaces and relationships. An initial barrier is awareness. When encountering uncertainty, physicians and patients may experience the presence of uncertainty on a spectrum of unaware to aware,^12,22 and the level of awareness may differ between individuals. Even when uncertainty is not explicitly communicated, patients may still sense the presence of uncertainty. In one study, the absence of transparent communication was described to result in a power imbalance termed traumatic uncertainty.²³ From this and other studies, we understand the importance of approaching uncertainty in a manner that centers a patient’s values, preferences, and agency.^24,25

Even when there is awareness of uncertainty, physicians and patients may experience barriers to communicating about it effectively. Physicians specifically may have self-doubt, anxiety, or associate higher uncertainty with the potential for medical error.^26,27 Physicians may also fear that voicing uncertainty to patients could diminish trust and satisfaction with care or otherwise harm the physician–patient relationship.^2,27 There are conflicting studies investigating the impact of disclosure of uncertainty on patient satisfaction.^28–32 A subset of these works have demonstrated negative impacts on patient satisfaction.^28–31 However, three of these were performed in standardized clinical scenarios and not in authentic practice settings.^29–31 In the real clinical environment, physicians may be more explicit in their acknowledgement and discussion of uncertainty than previous work suggests: at least one study examining encounters in a primary care setting found clinicians nearly always utilized expressions of uncertainty when explaining diagnostic reasoning to patients.³³ A separate study reviewing audio tapes of real clinical encounters between internal medicine physicians and patients showed direct acknowledgement of uncertainty in conjunction with information sharing and partnership building, and positivity was associated with patient satisfaction.³² Other works have also demonstrated positive associations between patient satisfaction and openly discussing uncertainty or physician tolerance of uncertainty.^32,34

Given these observations, it is important that all physicians develop effective approaches to situations of heightened uncertainty. Several tools are available to aid physicians in navigating difficult conversations with patients,^35–38 and some have relevance for situations of heightened uncertainty.³⁷ Additionally, an electronic medical record–based tool to guide discussions of diagnostic uncertainty has been shown to have usability among physicians and resulting patient satisfaction.³⁴ However, to our knowledge, there is not yet a pragmatic, structured approach that can help guide physicians through clinical situations of high uncertainty and that extends beyond the domains of diagnosis and communication.

In this narrative review, we propose a structured approach to assist clinicians in navigating uncertainty, in partnership with patients and colleagues. Our approach encompasses four steps: Recognize, Acknowledge, Partner, and Seek Support (RAPS) (Table 1). We provide examples for how RAPS can be applied flexibly to clinical cases (Table 3). We hope this framework can guide current clinical practice and inform future research to validate an evidence-based approach to navigating clinical uncertainty.

Table 1.

Components of the RAPS Framework for Navigating Uncertainty in Clinical Practice

Component	Purpose	Practical Tips
R: Recognize	To notice the presence of uncertainty and the potential for asymmetry in the perception of uncertainty	• Notice clinical and emotional clues that suggest high uncertainty on the part of the clinician • Notice linguistic, behavioral, or emotional cues that suggest high uncertainty on the part of the patient
A: Acknowledge	To name, accept, and normalize uncertainty	• Utilize clear language that names uncertainty • Anticipate emotional responses, allowing space and silence for these to come forward • Normalize that many different emotional reactions are possible, common, and welcome
P: Partner	To strengthen the therapeutic alliance with the patient and plan a course of action, employing partnering language and shared decision-making	• Communicate with empathy, transparency, and humility • Elicit patient’s preferences about communication, including level of information desired • Emphasize non-abandonment • Collaboratively formulate a plan, including initial steps, contingencies, follow-up, and a safety net
S: Seek Support	To gain information, clinical support, or emotional support to learn, grow, and reflect as a clinician	• Reflect on what was challenging or rewarding about the situation • Consider if you could you benefit from the input of another colleague or consultant • Consider what other formal or informal sources of learning and support are available to you • Speak about your experience with uncertainty and invite others to share theirs • Actively validate and normalize this dimension of practice • Incorporate discussions of uncertainty when working with medical learners • Seek spaces to discuss uncertainty inter-professionally

Table 3.

Case-Based Application of RAPS including Suggested Actions and/or Language

Quadrant (Table 2) and case	Recognize	Acknowledge	Partner	Seek Support
Quadrant A: Patient and clinician experience a low degree of uncertainty Case: A young female patient presents with an uncomplicated UTI, with no antibiotic allergies and no other known barriers to treatment	During the encounter, clinician and patient both use language that conveys confidence in the diagnosis and proposed treatment. Both experience low uncertainty	Not necessary	Not necessary	Not necessary
Quadrant B: Patient experiencing higher uncertainty than clinician Case: A patient with neurological symptoms and a comprehensive investigation is diagnosed with a functional neurological disorder (FND). The clinician is confident in this diagnosis but the patient is not	Clinician hears that patient is hesitant about the working diagnosis and proposed treatment plan and recognizes asymmetry in the perception of uncertainty between herself and the patient Suggested language: I wonder if you are feeling uncertain about the accuracy of the diagnosis. I am eager to hear about this and about any questions that you may have. How is the information that I have shared so far landing with you?	The clinician seeks to validate the patient’s experience of uncertainty, while sharing her perspective openly, even if discordant from that of the patient Suggested language: I understand your uncertainty. This is a disorder that is common, but one that we didn’t understand well, or know how to treat effectively, until fairly recently. It can be difficult not to be able to point to a specific lab test or imaging result to visualize the origin of your symptoms. I do feel that this is the disorder that you have, and I want to make sure that we make time to address all of the questions and concerns that you may have, both today and as we go forward	The clinician and patient formulate a plan that both incorporates the patient’s experience of uncertainty and also being medically appropriate from the clinician’s perspective. This may take several forms. It could include the offer of a second opinion. It could also include close follow-up with a plan for re-assessment and with very concrete guidance on what both the clinician and the patient should be alert to in the intervening time Suggested language: I am very committed to working with you to continue to treat your symptoms. Might it also be helpful to have you see another one of my Neurology colleagues to have a second opinion? This can be a way for us to make sure someone with a fresh set of eyes can think through your case. I would also like to see you again soon and I would like to discuss what I would advise that we do, and what we should look out for, in the time between now and then	Neurologist debriefs the specific patient encounter with practice partner later in the day. She also participates in regular multi-disciplinary review of the challenging FND cases referred to the clinic
Quadrant C: Clinician experiencing higher uncertainty than patient Case: A patient with diarrhea-predominant IBS is found to have Blastocystis hominis, often non-pathogenic, on a stool assay for ova and parasites. He understands this as a definitive explanation for the diarrheal symptoms, saying “I am glad that we finally have an answer,” but the clinician suspects this is likely a colonizing organism that is most likely not causing the symptoms	Clinician hears that patient feels certain about the causative connection between the laboratory result and his symptoms and notices the asymmetry in perception of uncertainty between himself and the patient Suggested language: I know how bothersome your symptoms have been and I want to make sure that we can review this result and the plan in detail	Clinician seeks to convey his own perception of uncertainty and foster greater alignment about the presence of diagnostic uncertainty. He may ask permission to share some additional information and perspective with the patient Suggested language: I know how important it feels to have a definitive answer for your symptoms. For a few reasons, I am not certain that this test result necessarily gives us the definitive answer. I would very much like to review my thinking with you in detail and provide time for all of the questions that you have	Clinician and patient formulate a plan that integrates the presence of uncertainty. They may engage in shared decision-making about whether to pursue antimicrobial treatment for the organism or to pursue watchful waiting with additional symptom-targeted management Suggested language: I am not certain that providing antibiotics for this will help your symptoms, and I do have some concerns that the antibiotics could potentially make your diarrhea worse. Let’s talk about all of the options together and come up with a plan that we are both comfortable with	Physician notices that this experience of asymmetry in diagnostic uncertainty has emotional valence for him in his practice He elects to discuss this with his colleagues, in his regular practice meeting where cases are reviewed as a group
Quadrant D: Patient and clinician mutually experience high degree of uncertainty about diagnosis and management Case: A 70-year-old male patient presents to his primary care physician with new debilitating fatigue; joint pain in shoulders, ankles, and knees; and elevated inflammatory markers. Comprehensive lab testing for infectious and inflammatory etiologies and cross-sectional imaging are performed and are negative	Patient and clinician mutually recognize that this is a new and undifferentiated illness Suggested language: I understand that these symptoms are new for you and are worrying you. It sounds like you aren’t aware of anything that may have brought them on and I agree we don’t yet know the cause	Clinician utilizes high-partnering language to acknowledge uncertainty, name emotions, and invite questions Suggested language: Based on our discussion and your examination today, I too am not certain of what is causing your symptoms. I do have several initial thoughts and ideas that I will share with you, and I am interested in hearing all of your questions and concerns. I would also like to recommend a series of tests and a clear follow-up plan. What questions and concerns do you have?	The clinician explains proposed next steps and elicits patient’s perspective and questions about each step. Close follow-up is arranged, with several visits occurring over the course of two weeks. Clear anticipatory guidance is given about alarm signs that should prompt more urgent re-evaluation. The clinician refers the patient to a trusted colleague in rheumatology While this is pending, the patient’s spouse in particular is very concerned that a diagnosis is not yet definitive Suggested language: I wish I could tell you with certainty what the diagnosis is. I understand your frustration. I’d like to review what we know so far, and what we still don’t know, and what the next steps are. I will make sure that my colleague in Rheumatology can see you as soon as possible and in the meantime, I want to make sure you know how to reach me for any new or different symptoms and I want to make sure we have a plan to control your pain After further assessment, the patient is treated with prednisone and the inflammatory episode resolves completely A clinical diagnosis of seronegative rheumatoid arthritis is ultimately made	The clinician reads about seronegative RA and shares case with peers She debriefs with a colleague the patient’s spouse’s high degree of frustration and receives informal peer support for this aspect of the relationship and the episode of care

A STRUCTURED APPROACH TO UNCERTAINTY: RECOGNIZE, ACKNOWLEDGE, PARTNER, AND SEEK SUPPORT (RAPS)

The four-part framework that we propose is an approach to guide the clinician in identifying, talking about, managing, and learning from uncertainty, in partnership with patients and colleagues. We envision its use particularly in scenarios where the dominant challenge is that there is not a discrete choice to be made among established options, there are conflicting guidelines or no guidelines at all, or there is high uncertainty in diagnosis or management despite initial, appropriate evaluation and care. As described in the cases (Tables 2 and 3), we also envision its use in scenarios where the clinician and the patient may experience asymmetry in the degree of perceived uncertainty.

Table 2.

Symmetric or Asymmetric Experiences of Uncertainty within the Patient-Clinician Relationship

	Clinician experience
		Low perceived uncertainty	High perceived uncertainty
Patient Experience	Low perceived uncertainty	Quadrant A Mutually experienced low uncertainty. Management of uncertainty with RAPS likely not warranted Case: A young female patient presents with an uncomplicated UTI, with no antibiotic allergies and no other known barriers to treatment	Quadrant C Physician experiences a greater degree of uncertainty in diagnosis, management, or prognosis than does patient Case: A patient with diarrhea-predominant IBS is found to have Blastocystis hominis, often non-pathogenic, on a stool assay for ova and parasites. He understands this as a definitive explanation for the diarrheal symptoms, saying “I am glad that we finally have an answer,” but the clinician suspects this is likely a colonizing organism that is most likely not causing the symptoms
	High perceived uncertainty	Quadrant B Physician experiences a lower degree of uncertainty in diagnosis, management, or prognosis than does patient Case: A patient with neurological symptoms and a comprehensive investigation is diagnosed with a functional neurological disorder (FND). The clinician is confident in this diagnosis but the patient is not	Quadrant D Both physician and patient experience a high degree of uncertainty surrounding diagnosis, management, or prognosis Case: A 70-year-old male patient presents to his primary care physician with new debilitating fatigue; joint pain in shoulders, ankles, and knees; and elevated inflammatory markers with a broad initial work-up that does not point to a specific diagnosis

R: Recognize

The first step in our framework is to Recognize when uncertainty is being experienced, by whom it is being experienced, and to what degree. Recognize also encompasses how we might consider the underpinnings of our perceived uncertainty and start to formulate a response. Prior research demonstrates that physicians at all stages of career are keenly aware of the ubiquity of uncertainty in clinical care. Nevertheless, there is the opportunity for physicians to grow in our ability to notice when we do not know, what we do not know, and to respond to our own limits in ways that are effective and adaptive.^15,16 Familiarity and comfort with one’s own emotional cues, and those of others, can help identify when uncertainty is present.³⁹ Some physicians and patients may experience stress or anxiety in the presence of heightened uncertainty, whereas others may experience a sense of curiosity or motivation.

A particularly rich dimension of uncertainty is that there can be a discrepancy in the amount of uncertainty perceived by the various actors within the therapeutic relationship (Table 2).¹² The physician and patient can mutually experience a low degree of uncertainty; the physician and patient can mutually experience a high degree of uncertainty; or there can be asymmetry in terms of the amount of uncertainty that is experienced. The Recognize step seeks to acknowledge that central to the navigation of uncertainty is the ability to build an awareness of the disparate perceptions and experiences of uncertainty that may exist between patient and clinician and other stakeholders.¹² While this concept is illustrated using four quadrants in Table 2, it is important to recognize that perceived uncertainty exists on a continuum^12,22 with more gradations beyond the simplified constructs of “low” and “high.” Nevertheless, the awareness of a potential asymmetry between actors in the clinician relationship may guide clinicians in choosing to employ the additional steps of the RAPS framework.

When engaging with situations represented in these quadrants, a physician must consider when a discussion about uncertainty with the patient is warranted. We suggest the following parameters to guide this decision: Does the patient raise the issue of uncertainty? Would an honest discussion of the uncertainty enhance patient knowledge, engagement, or empowerment or contribute to a therapeutic alliance? Would failure to acknowledge uncertainty engender dishonesty, or potentially harm? While these questions are not exhaustive, they may help guide the physician in the degree to which they engage with the next step of the RAPS framework: Acknowledge.

A: Acknowledge

Having recognized uncertainty, Acknowledging involves accepting, normalizing, and speaking about uncertainty. Acknowledging uncertainty opens the door to meaningful and honest discussions. Clinicians can employ language that emphasizes humility and non-abandonment, saying, for example, “I am not entirely sure what is causing your symptoms” or “I wish that I could answer that question more definitively, but I am not certain” or “Sometimes, even despite our best efforts, we can’t know with certainty the right course of action.”⁴⁰ Patients may have layered cognitive, emotional, and behavioral responses to these conversations, and the physician should welcome patients to discuss their cognitive and emotional responses.⁴¹ They can say, for example, “It can be difficult and even frightening to not know something with certainty. I am interested in hearing the thoughts and feelings that you are experiencing.” Allowing the space to discuss emotions can itself be therapeutic, and can guide the clinician in what forms of additional support the patient may need.

We view open discussions about uncertainty as having many potential benefits, both for individual patient and clinician, for the therapeutic alliance, and more broadly, for the promotion of trust in the profession. A willingness to name uncertainty and speak about it in detail reflects honesty and humility on the part of the clinician. These discussions may help to equalize power within patient-clinician relationships and promote patient agency. The next step of the framework, Partner, can be utilized to guide the way forward.³⁹

P: Partner

To Partner is to invest in a therapeutic alliance and to construct a mutually acceptable plan of action. When uncertainty is experienced or voiced by the physician, the patient, or by other actors within the clinical scenario, there may be hesitancy or anxiety about the care and ambiguity about how to proceed. We advocate an approach that combines the use of partnering language⁴² with the collaborative formulation of a plan that feels appropriate and safe for all of the actors within the clinical relationship.

In the literature on uncertainty, partnering communication styles are those that convey empathy, transparency, and a verbal commitment to collaboration and shared decision-making.^33,42,43 A longitudinal patient-physician relationship can be a powerful foundation for partnership,²⁷ but effective partnership can take place even in the absence of an established or longitudinal relationship.^34,42,43

As a plan is formulated, patients and clinicians may have differing views on how to proceed with care, particularly if there is asymmetry in the degree of uncertainty experienced (Table 2 and 3). Patients and clinicians may also have varying degrees of uncertainty tolerance, even if they perceive the presence of uncertainty similarly. All of this necessitates that clinicians be adaptable in how they share information and formulate a plan of care. Some strategies that can guide decision-making in the setting of uncertainty include the use of teaching materials, such as visual aids, to describe the next steps in a patients’ care, or the use of rounded probability ranges when discussing diagnostic options or outcomes.^44,45 A co-constructed, actionable plan of care should outline immediate next steps as well as contingencies based on the outcomes of these steps. This practice is called safety netting.⁴⁶ Clinicians can articulate clearly what is known, in addition to what is unknown. Clinicians can also affirm that, regardless of the uncertainty in diagnosis, management, or outcome, the physician will not abandon their commitment to caring for the patient.³⁹ For example, as suggested by Gheihman, one may say “I don’t know exactly what is going on, but I will be with you and will support you.”³⁹ Emphasizing non-abandonment can create a sense of certainty in the relationship itself.

By embracing partnering language and a collaborative approach to action, physicians can harness not only their own knowledge, motivation, and resilience, but also the patient’s knowledge, motivation, and resilience as they navigate the next steps collaboratively.

S: Seek Support

The final step of the framework, Seek Support, encourages clinical practitioners to think of uncertainty as an aspect of our practice that is deserving of enhanced peer support. It provides the opportunity to conceptualize uncertainty in clinical practice as a catalyst for curiosity, growth, reflection, and learning. It reminds us to consider the broader professional community of practice to which we belong and to consider our own need for supportive, partnering relationships with our colleagues.

Caring for patients in a clinical environment imbued with uncertainty can be taxing. Communities of providers can collaborate in initiatives that assist one another in their shared experience of navigating uncertainty, exchanging best practices, and offering peer mentorship and support. Balint groups are one venue in which a physician can gain perspective and insight into their practice from their colleagues.⁴⁷ A conversation with a trusted colleague or mentor can serve a similar purpose. Additionally, seeking the insights and expertise of colleagues, both within and outside one’s own institution, can provide important perspectives and opportunities for learning.³⁹ Sharing the experience of uncertainty may help generate new ideas or directions for patient care and for quality and process improvement. Experiences with uncertainty can catalyze self-directed learning, promote new avenues for research, and participation in continuing medical education. Equally important, such conversations help normalize the experience of clinical uncertainty and may foster wellbeing. Where possible, it is important to include trainees in discussions about our experiences with uncertainty. The ability to role model the approach to uncertainty can help less-experienced colleagues develop their own comfort.¹⁶ Finally, physicians can seek to ally with other health professionals in creating spaces where issues of uncertainty can be discussed across disciplines and roles, in order to generate collective insight and mutual support around our shared and differing experiences of uncertainty.

CONCLUSIONS AND AREAS OF FURTHER STUDY

The constant evolution of medical knowledge and the layered biopsychosocial dimensions of the clinical environment imbue our work as physicians with uncertainty. Previously the field of uncertainty research largely focused on describing the presentations and etiologies of uncertainty and its effects on physicians and patients. Here we have proposed a practical approach for navigating uncertainty in daily clinical care that assists physicians in recognizing uncertainty and asymmetry in the understanding or tolerance of uncertainty, communicating systematically and authentically with patients, co-creating a plan of action, and utilizing uncertainty as an opportunity for personal and professional connection and growth. In understanding uncertainty as a specific dimension of clinical care worthy of specific approaches, we hope to bring heightened visibility to the ubiquity of uncertainty both in the relationship between patients and their physicians, as well as among communities of practitioners. Future research is needed to evaluate the efficacy of the language and the approaches that we describe in clinical practice and their outcomes on patients and physicians.

Declarations

Conflict of Interest

The authors do not have any conflicts of interest to disclose.