Bearing the Burdens of Medical Uncertainty

Abstract

Rationale:

Uncertainty comes in many kinds, is ubiquitous in all parts of clinical work, and is burdensome to physicians, patients, proxies and policy makers. Moreover, it leads to a range of adverse responses such as excessive testing and interventions, overdiagnosis and overtreatment. While the technical aspects of uncertainty are widely accounted for, the burdens of uncertainty need closer scrutiny.

Aims and Objectives:

The aim of this article is to investigate the complex burden of uncertainty for clinicians: as health professionals, carers for patients, and human beings facing the unknown.

Method:

A conceptual analysis is applied introducing a case to illustrate the diverse aspects of uncertainty reviewed in the literature.

Results:

We identify six types of burdens of uncertainty: cognitive, emotional, behavioural, social, moral and existential and show how they play out for clinicians in clinical care for their patients, as health professionals, as caregivers and human beings. Moreover, we suggest specific strategies for bearing these various types of burdens of uncertainty in all roles.

Conclusion:

Bearing the burdens of uncertainty is crucial for professional integrity, well-being, and communication with patients, but also for improving the quality, safety, efficiency and sustainability of healthcare.

1 |. Introduction

Case:

Bill, 55, goes in for a regular checkup with his GP and gets a PSA test, which turns out to be mildly elevated. This makes him anxious. The physician tries to explain that the positive test does not mean that he has cancer. She informs Bill carefully about false positives and potential confirmatory tests. Nonetheless, Bill’s sense of self-integrity is challenged. What if he has cancer? How will this change his life? How will it affect his relationship to his wife, children, and friends and how will it influence his work and career? On the other hand, Bill feels healthy. “Am I really ill?” he asks himself. When informed about the options, Bill is uncertain about what to do. Should he go for further biopsies or diagnostic imaging tests, engage in repeated PSA testing, or should he assume that it was a false positive and simply resume regular PSA tests? The physician is uncertain about the best option but explains all alternative outcomes and known probabilities carefully. Nonetheless, Bill finds it difficult to decide. Eventually, he goes for repeated PSA testing in one month, which was slightly improved from the prior value but in the borderline abnormal range. However, Bill continues to be worried. It affects his thinking about his career and life planning. He thinks that if he does not follow up with biopsies, he will regret it. His physician is uncertain whether it is too early but refers Bill to biopsy. Of 12 biopsy samples that are taken, one sample turns out positive for cancer. It is found to have a low-grade tumor (Gleason 3 + 3). Imaging studies show no evidence of more extensive disease. While Bill’s physician tells him about the good prognosis of localized, low-grade cancer, he gets anxious. When she informs him about the treatment options of active surveillance, surgery, and radiotherapy, Bill gets very unsure. Bill asks his physician what she recommends, and they discuss his values and preferences. When she asks, Bill says “it feels like a ticking bomb inside me.” “The uncertainty of whether or not I will become ill and die is unbearable, and the uncertainty of whether I do the right thing is haunting me.” The physician is uncertain about the best option and finds it hard to advise Bill.

The case of Bill illustrates how uncertainty can be a burden to clinicians and patients, how some aspects are different while others are shared. It also illustrates how uncertainty is a complex state that pertains not only to technical aspects of healthcare, such as the (in)accuracy of diagnostic tests (in terms of false-positive and -negative test results) and the benefits and harms of treatment alternatives. Bill’s and his physician’s uncertainties were not simply cognitive in their nature, focus or effects. They were also emotional and behavioural, and encompassed social, moral and existential issues. Hence, to help both parties manage these uncertainties, we need to more comprehensively address their effects—to account for the whole range of the burdens of uncertainty.

Greater attention to the burdens of uncertainty is a critical need in several domains of healthcare. In clinical practice, it enables healthcare providers to better understand their patients’ uncertainties and to mitigate harmful responses to these uncertainties. In medical education, it enables future clinicians to learn effective uncertainty management strategies that can improve not only their patients’ well-being but their own. Additionally, it can prevent adverse measures such as excessive testing and treatment, and thereby improve the safety, quality and sustainability of healthcare.

Acknowledging and understanding the broad spectrum of uncertainty’s burdens for clinicians as well as patients can foster more sound, deliberate decision-making, respectful and effective communication and clinician integrity [1]. Clinicians bear a ‘double burden’ of uncertainty corresponding to the dual role and perspectives they must accommodate in their clinical work: as professionals, who must confront and manage uncertainties that are specific to the delivery of healthcare, and as caregivers, who must consider and contend with uncertainties that are experienced by their patients with particular health problems. Moreover, some aspects of uncertainty are more fundamental; they are shared by all human beings and integral to the act of living—connecting patients and professionals. Greater attention to these many different burdens of uncertainty for clinicians is a first step in helping people obtain comfort with it [2], and achieving high quality, safe, effective and sustainable healthcare.

Accordingly, the objective of this paper is to promote greater knowledge and awareness of the burdens of medical uncertainty for clinicians and patients, to describe the unique ‘double burden’ faced by clinicians as a result of their dual professional role, and to suggest strategies clinicians can use to more effectively bear these burdens. We will do so by answering two key questions:

1. What are the cognitive, emotional, behavioural, social, moral and existential burdens of medical uncertainty for clinicians as professionals, as caregivers and as human beings?

2. How might clinicians bear these burdens of uncertainty and help their patients to do so?

We will develop conceptual frameworks that classify the range of both the burdens of medical uncertainty and the strategies that can be used to manage them and conclude by laying out an agenda for future research on this important topic.

2 |. The Burdens of Uncertainty: Shared and Unique

In general, uncertainty comes in many kinds and is prevalent in all domains of healthcare practice and research [3–12]. It confounds medical decision-making at all levels, for example, in clinical diagnosis, prognosis and treatment, and in public health and health policy making. Much attention has been paid to the various objects of medical uncertainty, such as the accuracy of diagnostic tests and the efficacy, effectiveness and efficiency of treatments, as well as the precision of clinical predictions. There is also an extensive literature on the psychology of uncertainty [13–15] and on how to tolerate uncertainty [16–22]. Much less attention has been paid, however, to the double burden of uncertainty for clinicians and uncertainty’s potential for mutual understanding and fruitful interaction.

As the case with Bill illustrates, our quests to address the objects of uncertainty, for example, by undertaking more tests and trying more treatments, often ends up increasing uncertainty and its burdens on both patients and physicians [7, 23–27]. Instead of reducing uncertainty, we come to increase it.

While uncertainty is experienced on several levels, for example, by patients, clinicians, managers, health policy makers, and politicians, in this article we focus on the experience of uncertainty for individual clinicians as professionals and as caregivers for patients. As such uncertainty is associated with a range of burdens: cognitive, emotional, behavioural, social, moral, existential and also financial and economic. Some of these burdens are unique to clinicians. Others are unique to patients and relevant to clinicians as caregivers. Yet others are general to human beings and life experiences beyond healthcare and are shared by both patients and professionals and provide opportunities for relationship and communication [28].

We believe it is useful to distinguish these disproportionate burdens, which we present in the framework below as specific burdens—although we emphasize that this distinction does not mean that they are exclusive to one party or the other.

Table 1 provides a description of the cognitive, emotional, behavioural, social, moral and existential burdens of uncertainty Some of these burdens are more unique to clinicians and patients, while others are shared. As caregivers, clinicians need to be aware of the burdens of uncertainty for patients. Moreover, the shared burdens can foster mutual understanding and more effective physician–patient interactions.

TABLE 1 |.

Overview of the various types of uncertainty for clinicians as professionals and caregivers as well as shared as human beings including examples from the case with Bill.

	Clinicians	Patients	Shared
Cognitive	Clinicians may experience unique cognitive burdens given cultural, professional and personal expectations, including dissatisfaction with not being able to provide sufficient information, which may manifest as self-condemnation [10].	Patients may experience unique cognitive burdens including self-doubts focused on specific concerns, for example, ‘Am I ill?’ or ‘Is my suffering real?’ or ‘Is this the right diagnosis?’ Clinicians can exacerbate this unique patient burden, furthermore, if they dismiss or stigmatize patients with uncertain diagnoses [29, 30].	Both Bill and his physician found it difficult to cognitively understand the meaning of the test results for Bill. Accordingly, both patients and clinicians may experience diffidence, dissonance and ambivalence, as cognitive manifestations of the conscious awareness of their ignorance about some aspect of the world [31]. Moreover, patients and clinicians may have shared cognitive experiences of both disappointment and general mistrust in response to the lack of knowledge.
Emotional	Clinicians may experience shame when they are not knowledgeable or able to provide patients with sufficient information or advice. Other emotional burdens unique to clinicians include feelings of devastation and remorse, which can exacerbate other negative emotional responses. As described by Lowe: “I feel ashamed of my inadequacy … I feel devastated ….” [32].	Patients may experience unique emotional burdens including fear, which may be particularly intense given one’s own health or survival may be at stake in decisions involving uncertainty. As in the case of Bill, many patients fear illness and death, which can exacerbate emotional distress and regret in conditions of uncertainty [33]. Decision making is particularly distressing when high-stakes decisions are involved, as illustrated in the case of Bill.	Uncertainty evokes shared emotional burdens including fear, worry, discomfort [34–36] which in turn exacerbates cognitive dissonance and diffidence both in patients and clinicians. Uncertainty is a fundamental source of anxiety, worry and discomfort in human beings. Anticipated regret is a potent shared emotion that influences behaviour and can exacerbate the burden of uncertainty [37, 38],
Behavioural	Clinicians may exhibit evasion, prompting them to relinquishment of decision-making responsibility to patients. They may abandon efforts to help patients make difficult decisions. Alternatively, patients’ passivity and disengagement might compel clinicians to act decisively, or even paternalistically, as explored further below.	For patients, the distinct behavioural impacts of uncertainty can manifest not only as decision deferral or avoidance but also passivity, disengagement and relinquishment of their decision-making authority to clinicians.	Both patients and clinicians may exhibit varying degrees of decision deferral or avoidance in response to various uncertainties of clinical care. As in the case of Bill and his GP, both experienced difficulties in deciding on further testing. Decision deference or avoidance are well-described phenomena of risk aversion, ambiguity aversion and complexity aversion [16, 17] and may result from doubt about the self-efficacy and the “capabilities to organize and execute a given course of action” [39].
Social	Clinicians may experience marginalization, such as being relegated to reduced social roles or witnessing a decline in their social standing and professional prestige [40]. Uncertainty compels clinicians to adopt new professional roles and identities in relation to their patients, where they may no longer possess the same level of expertise or authoritative decision-making power [41]. Similarly, uncertainty can alter clinicians’ relationships with colleagues, potentially undermining their sense of professional integrity [1] and esteem: ‘I’m worried that in 3 days from now I’m gonna get some angry email from some angry orthopedist telling me that I’m a bad doctor’ [42].	Uncertainty can affect patients’ ability to fulfil usual social roles—such as being employees, partners, parents or community contributors—as well as their adherence to cultural expectations or norms associated with these roles [43, 44]. For instance, Bill was deeply concerned about his social relationships and career. Patients can also feel exclusion or alienation from their usual social groups and relationships.	Disruptions to established social roles and identities impact both patients and clinicians. However, role ambiguity generates distinct challenges for both patients and clinicians.
Moral	Uncertainty places uniquely heavy moral burdens on clinicians, encompassing the distress of navigating ethically challenging situations [7] and the profound sense of responsibility for the welfare and life of those in their care. In response to patients’ surrender of decision-making, clinicians might adopt a paternalistic approach [36] or become morally resigned. ‘I’m not going to focus on this anymore because there’s nothing I can do about it’ [45]. Hence, they may experience that the moral imperative to help may be reduced when there is uncertainty (about the patient’s diagnosis, treatment options or prognosis).	Uncertainty places uniquely heavy moral burdens on patients, given that their health, well-being, and very existence is at stake; high-stakes medical decisions are especially morally distressing. In our example, Bill became worried for how he could care for his family (moral agency). Relatedly, patients may become disengaged and relinquish their moral agency, which may be manifest in complaints such as ‘you are the doctor, you should know’ [46].	Both patients and clinicians may be burdened by moral conflicts or distress about their most fundamental life values [3]. For example, cancer patients like Bill may be uncertain about whether to undergo or forego treatment due to a conflict between their own values and preferences and those of their loved ones [7]. Uncertainty may also lead both patients and clinicians to feel less helpful to others than they want to be, exacerbating moral distress [47]. Many medical uncertainties pertain to the most basic and profound issues of life, such as health, disease and dying, heightening the sense of moral responsibility and culpability felt by both patients and clinicians [48].
Existential	Uncertainty can also impose existential burdens on physicians, including feelings of powerless and purposeless. Accordingly, uncertainty may make professionals experience disenchantment and lack of meaning and purpose. Burnout and professional dissatisfaction are well-known effects of a lack of meaning and purpose in one’s career [22, 49, 50].	Patients, in particular, can experience intense levels of dread and despair due to the life-or-meaning-threatening implications of a health condition on their own existence. As pointed out by Adamson, ‘the disclosure or reminder of clinical uncertainty can exacerbate existential uncertainty, provoking anxiety, breakdown or psychological denial which may, in turn, lead to non-compliance with medical instructions’ [51].	Related to its moral burdens, medical uncertainty may also impose shared burdens of existential distress upon both patients and clinicians, which pertain to not only the possibility of one’s death or non-being [52, 53], but to a loss of a sense of meaning or purpose in life [54–57]. While the ‘patient’s project involves learning to live with the chaos of lost control’, the existential uncertainty of the patient influences the clinician as ‘the identities of clinician and patient are symbolically constructed through mutual interaction. As social actors, the physician and the patient imagine each other’s inner’ [51].

Figure 1 provides an overview of the burdens of uncertainty that are both unique and shared by clinicians and patients, and that are cognitive, emotional, behavioural, social, moral and existential in nature. The arrow indicates the interconnected nature and strong dynamic interactions between the various types of burdens for both parties. For example, existential burdens (e.g., despair) can produce emotional burdens (e.g., distress) for patients. Correspondingly, emotional burdens (e.g., shame and remorse) can produce behavioural (e.g., evasion) and existential (e.g., powerlessness) burdens for clinicians. Furthermore, any of the burdens experienced by one party can influence the burdens experienced by the other. Although these many specific types of burdens are conceptually distinguishable, they are tightly interconnected and interdependent. Nevertheless, it is useful to separately consider each type of burden and the extent to which they are shared or unique to patients and professionals.

FIGURE 1 |.

Overview of burdens of uncertainty that are shared by and unique for patients and clinicians.

Given this complex framework of burdens of uncertainty, the critical question is, how can clinicians effectively cope with or bear these burdens?

3 |. Bearing the Burdens of Uncertainty

Several strategies have been suggested to acknowledge, manage and tolerate uncertainty [16, 45, 58–60]. Bearing uncertainty seems to go beyond the passive acceptance of uncertainty yet has more modest ambitions than complete control or mastery. Furthermore, bearing the burden of uncertainty requires openness and flexibility, given that there is no single ‘correct’ or ‘adaptive’ way of bearing the burden of uncertainty for all individuals and situations. However, we believe that as guiding principles, some approaches are less adaptive and should generally be avoided, whereas others are more adaptive and should generally be promoted.

The effectiveness and suitability of any strategy to handle the burdens of uncertainty must be tailored to the specific context. Nonetheless, we believe that existing empirical evidence on the nature and management of uncertainty points to several promising strategies that could assist clinicians in managing the burdens they encounter as professionals and caregivers, and that the shared experiences of uncertainty can foster mutual understanding and fruitful physician-patient interactions as fellow human beings engaged in facing uncertainty together.

These strategies can enhance clinicians’ ability to handle the distinctive professional uncertainties involved in delivering healthcare, address the uncertainties experienced by their patients, and address the personal uncertainties shared with their patients. Additionally, these strategies may enable clinicians to deliver care more effectively, respond more sensitively to their patients, and foster the well-being of both themselves and their patients. While the following strategies are not exhaustive or exclusive, they offer a valuable overview and provide a practical starting point for deeper exploration.

Figure 2 provides an overview of the patient- and clinician-directed management strategies to bear each of the burdens of uncertainty. Below follows a detailed description of each strategy.

FIGURE 2 |.

Overview of strategies for clinicians to bear the burdens of uncertainty.

3.1 |. Cognitive Burdens

The many cognitive burdens of uncertainty—including self-conceptions of epistemic inadequacy and vulnerability—raise the need for strategies that promote cognitive acceptance and serenity (ataraxia). Such strategies include cognitive reframing, epistemic adjustment, endurance and epistemic candor [16, 45]. As in Bill’s case, the GP practices honesty, openness and acceptance about the limitations of her knowledge. This helps her to engage with Bill in shared decision making. Moreover, she respects Bill’s understanding of his illness and his preferences for different choice options. However, as the case illustrates, this is not easy, and openness about professional uncertainty does not always promote patient confidence and satisfaction [61].

Clinicians can assist patients in managing the cognitive burdens associated with scientific uncertainties regarding diagnosis, prognosis, causes and treatment in various ways. By tailoring their communication to align with patients’ informational preferences and the specific demands of each situation, clinicians can effectively support their patients. Studies highlight the importance of being transparent about the inherent uncertainty in medical options and explaining the strength and nature of the available evidence. As demonstrated in Bill’s case, outlining potential scenarios and discussing their implications can help patients organize uncertainty, form realistic expectations about their condition and potential outcomes, and assess whether the existing evidence warrants action. The extensive literature on how clinicians should communicate uncertainty [62] offers valuable insights to help alleviate the burden of uncertainty for patients. Shared decision-making [63] is but one relevant approach.

3.2 |. Emotional Burdens

The many emotional burdens of uncertainty—including anger, discomfort, distress, shame, catastrophizing or evasion—raise the need for strategies that promote effective emotion regulation [64–66]. For clinicians, this can involve identifying and compartmentalizing negative feelings of previous decisions and focus on future judgments [16, 45]. It can also involve sharing negative feelings with colleagues or peers [67, 68].

Actively responding to emotions is a key element of patient-centred communication [69] and relationship-centred care [28] and a critical strategy for helping patients bear the emotional burden of medical uncertainty. Instead of passively accepting or disregarding Bill’s (exaggerated or irrational) reactions to the test results and management options, the clinician could actively elicit and respond to the patients’ emotions and offer support as needed [62].

Emotional support can be provided formally through psychotherapy or other clinical interventions, or informally through relationship building and empathic, patient-centred communication [16, 69]. In everyday interactions with patients and loved ones, clinicians can affirm their continuous support and availability, aiding emotional coping through consistent presence and engagement. By expressing calmness, reassurance and comfort, they foster a supportive, psychologically safe environment. Demonstrating empathy significantly alleviates patients’ worries [70], while affective communication by physicians can help mitigate patients’ anxiety in uncertain situations [71].

3.3 |. Behavioural Burdens

The many behavioural burdens of uncertainty—including disengagement, deferral, evasion, information avoidance or excessive testing—raise the need for strategies that promote diligence, engagement and focused attention [16, 22, 45, 72, 73]. For example, Bill’s GP tries actively to acknowledge Bill’s challenges with facing with the test results and management options. Correspondingly, clinicians can be cautious to avoid maladaptive compensatory behaviours, such as excessive testing and treatment.

Moreover, clinicians can engage patients in relationship-centred care (RCC) [28] and shared decision making (SDM), and thus help them bear the often formidable burden of choosing between medical options when scientific evidence is lacking or the implications of different options is not clear [74]. While RCC and SDM may not remove or reduce the uncertainty, it may make clinicians help patients to elicit and clarify their values, encourage decisions that are consistent with these values, and help patients feel more confident about their choices, once made. However, clinicians must guard against the temptation to use SDM as a means of disengaging from uncertainty and relinquishing all decision-making responsibility to patients. Rather, clinicians must remain actively engaged partners in the decision, providing their own perspective and working closely with their patients to identify relevant ‘coping strategies, management plans and responses to future uncertainty’ [62]. The ultimate goal is to reduce uncertainties that are reducible, and to palliate uncertainties that are irreducible—that is, to co-develop strategies to mitigate the suffering they cause [16, 45]. As demonstrated in Bill’s case, understanding potential scenarios and available actions is crucial.

3.4 |. Social Burdens

The social burdens of uncertainty—including role disruption, confusion and disregard of uncertainty [75]—raise the need for strategies that promote openness, transparency and ongoing role negotiation and development. Such openness and transparency can foster—rather than diminish—trust and is preferred by patients [30]. Being clear about both the capabilities and limitations of medicine can thus help clinicians manage the social burdens of uncertainty and maintain their professional standing. While the effects of openness are diverse [61], in the case of Bill, the GP’s openness did not reduce his confidence and trust.

Additionally, clinicians can help patients adapt to their changing (sick) role and its impact. For example, Bill’s GP was attentive and reassuring with respect to his concerns about future career plans. Accordingly, clinicians can promote patient trust in clinicians by being responsive, calm, reassuring, and secure even when uncertain—normalizing the uncertainty as an expected state of affairs that both parties must accept and address. Clinicians can also be sensitive to how uncertainty (and disease) will affect the social roles and responsibilities of their patient, for example, with their family, friends, communities, organizations, and so forth. They can help patients explore how to navigate, maintain, or alter their roles and responsibilities if necessary, and help link patients to available social support services [16].

3.5 |. Moral Burdens

The moral burdens of uncertainty—including moral dissonance and distress, as well as guilt—raise the need for strategies that promote self-acceptance and self-forgiveness [16, 45, 76], as well as greater understanding of the nature of moral dilemmas and one’s responses to them [77, 78]. Lowering moral expectations and responsibility is crucial both for patients and clinicians.

Cultivating (epistemic) virtues such as equanimity, flexibility and openness can help clinicians to manage their own moral doubt and numbness in situations of uncertainty [16, 17, 79, 80]. Such strategies are important especially to avoid the extremes of paternalism (appearing certain when not warranted) or moral abandonment (relinquishment) and to reinforce the moral imperative (duty to help) even when the epistemic basis is uncertain.

Moreover, clinicians help patients bear the moral burdens of uncertainty by encouraging their moral agency and autonomy and engaging them in shared decision making (SDM). While SDM certainly also can increase the burden of uncertainty, it can be used to structure physician-patient interaction and strengthen their moral agency, for example, by eliciting patients’ preferences and involving them in decision-making. While some patients prefer to cope with the moral burdens of uncertainty by deferring decision-making responsibility to clinicians, the ethical principle of respect for autonomy requires clinicians to provide at least a basic level of information and to involve patients in decision making to the greatest extent possible, consistent with their values and preferences. Moreover, clinicians can help persons who consider themselves to be a (moral) burden to others, by promoting their self-efficacy [27], for example, by confirming their human worth and dignity (independent of their moral agency) and helping them to understand that receiving (and not only giving) help is crucial for moral agency.

3.6 |. Existential Burdens

The existential burdens of uncertainty—including despair, meaninglessness and powerlessness —raise the need for strategies that promote self-acceptance, purpose and meaning. Re-focusing attention on medicine’s original moral goal, that is, to comfort, care for and help suffering individuals, is a key strategy that can enable clinicians to manage the existential burdens of uncertainty [81, 82]. Moreover, clinicians can help patients avoid or alleviate despair and dread by providing hope, for example, by underscoring that uncertain results are uncertain about whether they are positive or negative. In the case with Bill, his GP highlighted the uncertainty of the test results, underscoring the good prognosis. She was also attentive to how uncertainty incited existential burdens, provoking anxiety.

Accordingly, clinicians can help the patient learning to live with the sense of powerlessness that uncertainty may engender or exacerbate [51]. They can promote courage by demonstrating and encouraging openness to alternative courses of action and entertaining future possibilities [54]. Moreover, they can promote self-acceptance and a sense of meaning by providing relational support and encouraging social connections with family and friends [51, 54, 55, 74, 83].

4 |. Discussion

In this paper we have identified a broad range of cognitive, emotional, behavioural, social, moral and existential burdens of the many uncertainties in medicine. Moreover, we have unravelled the double burden of uncertainty that clinicians bear as a result of their simultaneous roles and perspectives: as professionals dealing with uncertainties of medical science and practice and as caregivers dealing with uncertainties of their patients. Additionally, we have argued that uncertainty imposes more fundamental, shared human burdens that are independent from the roles played by clinicians and patients, and that bind clinicians and patients together, providing opportunities for mutual understanding and fruitful interaction.

As we have laid it out, the task of bearing the burden of uncertainty is more ambitious than mere acceptance or endurance, and less aspiring than mere control or coping. We think it is appropriate to avoid the impression that the burdens of uncertainty can be fully controlled or completely mitigated or coped with. Bearing the burdens of uncertainty in medicine is a never-ending, incomplete, dynamic work-in-progress that requires ongoing, active engagement of clinicians and patients who each represent unique individuals (biologically, mentally, socially and existentially) [84]. Moreover, there is no single ‘right way to bear the burdens of uncertainty’ in any given situation. The great challenge of this task for both clinicians and patients is to be sufficiently creative and flexible to develop optimal strategies for their own unique circumstances.

We believe that acknowledging and detailing the burdens of uncertainty is the first step towards meeting this challenge. We have attempted to identify the uncertainties and pinpoint potential strategies for managing these uncertainties, and we believe that this exercise could help both clinicians and patients adopt a more intentional approach to the task. Explicitly and comprehensively accounting for the burdens of uncertainty and elaborating relevant strategies to bear them has manifold benefits. First, it may help clinicians develop intentional, focused strategies to preserve and maintain their sense of professional integrity. Second, it may promote mutual understanding of the effects of uncertainty among clinicians and patients and improve patient-physician communication. Third, it can facilitate the development of new, uncertainty-focused strategies to address various known healthcare quality problems—for example, unnecessary testing and intervention, defensive medicine, overdiagnosis and overtreatment [85–87]—that may ultimately represent detrimental or maladaptive responses to uncertainty. Fourth, it may promote the development of more effective, uncertainty-focused interventions to improve patient and clinician well-being and personal and professional satisfaction. In these ways and more, a fuller accounting of the burdens of uncertainty could ultimately increase the quality, safety, efficiency and sustainability of care.

A focus on the burdens of uncertainty can also advance empirical research to understand and improve the management of uncertainty in medicine. It suggests the need for further research to understand how clinicians and patients manage and tolerate uncertainty. Although there exists a range of instruments to measure perceptions of uncertainty in healthcare and related constructs such as uncertainty tolerance [17], more work is needed to develop ways of assessing the broad range of the burdens of uncertainty for patients and clinicians. The conceptual framework presented here might serve as a useful starting point for such work—for example, for developing a burden of uncertainty index, analogous to the burden of disease index [88], that encompasses the range of cognitive, emotional, behavioural, social, moral and existential burdens of uncertainty [89, 90].

Greater attention to the burdens of uncertainty also has implications for medical education [85]. We need to improve awareness and knowledge about the burdens and harms of uncertainty for medical learners as well as teachers. By highlighting the burdens, influencing factors, and strategies to mitigate the burdens of uncertainty for healthcare professionals and patients, our conceptual framework might help foster reflective practice among medical trainees, and greater capacity to cope with medical uncertainty.

Finally, attention to the burden of uncertainty may also have implications for healthcare policy and management. More effective management of uncertainty by clinicians and patients may help improve healthcare quality and safety in various ways, including decreasing low-value diagnostic testing and treatment, and promoting more appropriate use of healthcare resources.

We emphasize that the burdens of uncertainty are interconnected, dynamic and interactive: one burden can lead to another, while on an interpersonal level, the burdens experienced by one party can affect the burdens experienced by the other. For example, the cognitive and behavioural burdens of clinicians shared with patients, have great implications for the emotional, social, moral and existential burdens for the patient [51], as also illustrated in the case of Bill.

Many attempts have been made to measure medical uncertainty [89–91], and to handle it in various ways, including minimizing or reducing it [73], accepting, adapting to, tolerating [17], compensating for [92] and managing it [3, 12, 23, 92–102]. Nonetheless, medical uncertainty still haunts patients, physicians, researchers, as well as healthcare policy makers. One reason may be that not enough attention has been devoted to the burden of uncertainty. Moreover, there is an interplay between the burdens as the relief of one burden may result in an extra burden of another, and the relief for one person may result in an increased burden for the other. This burden mismatch is an important topic warranting further study.

As previously noted, neither the list of burdens nor the suggested strategies to bear them are exhaustive or exclusive. Much more can be said about each of them and the relationship between them. However, the intention here has been to provide an overview which could serve as a useful provisional guide for clinical practice.

A clear limitation of this article is that it has focused on bearing the burdens of uncertainty and characterized its effects as exclusively negative. Clearly, however, there are many positive aspects of uncertainty, such as inciting hope, inspiring creativity and spurring curiosity [17], that require greater attention. However, the objective of this article was to approach uncertainty through the lens of the basic telos of medicine to relieve human suffering [82]. How uncertainty influences wellbeing and strategies to promote such effects warrants a separate study.

5 |. Conclusion

Despite extensive advances in science and technology medical uncertainty prevails. Clinicians bear a double burden of uncertainty; first, as professionals and second as caregivers when considering and contending with uncertainties that are experienced by their patients. Moreover, clinicians and patients share burdens of uncertainty that may foster mutual understanding and fruitful interaction. In this article we have studied six types of burdens: cognitive, emotional, behavioural, social, moral and existential burdens of uncertainty.

Moreover, we suggest specific strategies for bearing the burdens of uncertainty. More attention and better strategies to bear the burdens of uncertainty can avoid adverse responses, such as excessive testing and interventions, defensive medicine, overdiagnosis and overtreatment and can improve the quality, safety, efficiency and sustainability of healthcare.

Data Availability Statement

Data sharing not applicable to this article as no data sets were generated or analysed during the current study. All data is available in the publication.