How do psychiatrists manage clinical uncertainty?

Lucia Sommers of the department of family and community medicine at the University of California, San Francisco commented on my last post, noting that clinical uncertainty among primary care physicians (PCPs) is usually regarded as tolerable at best.  She was delighted that I called such uncertainty intellectually attractive, and something to embrace in psychiatry.  Sommers and her co-author John Launer recently published a book that argues for managing clinical uncertainty in primary care using “collaborative engagement with case-based uncertainty in the setting of small groups of clinicians.”  This contrasts with medicine’s tradition of practitioners working independently.

In her comment, Sommers asked me to describe how psychiatrists manage clinical uncertainty, and specifically whether “supervision” — cases “presented for discussion to at least another psychiatrist if not a small group,” similar to what she advocates for primary care physicians — is a good strategy in my experience.  This post is my response.

At its most fundamental level, human psychology exists to manage uncertainty.  Confronted with an incomprehensible, threatening world, the infant soon differentiates “good” from “bad.”  Initially a crude split without nuance or shades of gray, this primitive psychological distinction,  second only to distinguishing “self” from “other,” represents a huge step forward.  It sets the stage for approach versus avoidance — the first “management” the infant undertakes.  Further psychological development allows subtler gradations to improve upon this harsh dichotomy.  Developmental psychology describes how secure attachment with caretakers, and an increasingly stable sense of self, contribute to tolerance of uncertainty.  With normal development, and under most circumstances, we no longer cling desperately to sharp black-or-white categories.  We make finer distinctions, and can also tolerate degrees of uncertainty.

Adult development takes this process further.  Mastery of an academic or occupational field solidifies a stable professional identity, which contributes to comfort with uncertainty.  Many years ago I learned a type of computer programming from my friend, an accomplished software engineer.  I felt anxious when confronted with programming challenges:  Would I fail to discover the solution?  Waste long hours trying?  Feel stupid in the end?  In contrast, my friend felt no such anxiety.  He explained that even when he was uncertain how to solve a problem, he knew he soon would, or at least would soon recognize it was impossible.  He was able to wrap his arms around the whole field in a way I could not.  Uncertainty for him no longer carried implications of permanence, nor of personal failure, i.e.,  narcissistic injury.  It wasn’t threatening.  In this frame of mind, a programming challenge is merely a puzzle, an engaging intellectual pursuit which can even be fun.

Although the stakes are higher, the same applies in medicine.  An intern faced with clinical uncertainty shares my erstwhile self-doubt as a beginning computer programmer.  Is my uncertainty humiliating?  A sign of failure?  Will I ever figure it out?  With more experience comes confidence that uncertainty isn’t psychologically threatening.  It’s an intellectually engaging puzzle, often with a gratifying emotional reward at the end.  In specialties such as primary care and psychiatry, uncertainty becomes the norm.  We get used to it, expect it; we realize it doesn’t tarnish us individually.

An additional factor that may sound esoteric but is crucial to thriving in uncertainty is the flow state.  Variously described as being “in the zone” in sports, “centered” in Eastern meditative and martial arts practices, and “in the groove” in musical performance, this is a mental state of heightened awareness, engagement, and creativity accompanied by a relative lack of self-consciousness and conscious intent.  Whether in extreme sports, music improvisation, video gaming, or academic brainstorming, moment-by-moment uncertainty is less disruptive and feels more welcome in the flow state.  Although uncommon in typical medical practice, the flow state can arise during intimate discussion with a patient, during research activities, and when intensely absorbed in medical work-up or treatment planning — the very times when clinical uncertainty is actively addressed.

Peers are a good source of emotional support whatever one’s level of expertise.  Seeing that a problem is inherently difficult is reassuring; its apparent difficulty does not reflect on oneself.  Social interaction bolsters self-esteem, and often humor is shared to defuse fear and anxiety.  Similar challenges shared by others promote camaraderie and a sense of being “all in the same boat.”  And tales of challenges successfully overcome can instill optimism, and sometimes offer practical solutions for the problem at hand.

My own experience with psychiatric supervision is hierarchical, not peer-to-peer.  Supervisors model a great deal non-verbally and often unintentionally: Our attitudes toward patients and their issues, the focus of clinical attention, our approach to formulating cases, levels of formality and informality, and so on.  The supervisor’s engagement with clinical uncertainty is one such factor, sometimes discussed explicitly, more often modeled non-verbally.  Ideally, this role-modeling inspires and encourages supervisees to nurture clinical curiosity, and to avoid frantic efforts to resolve uncertainty with premature conclusions.

Having not read the Sommers/Launer book, I cannot comment on their rationale for “collaborative engagement with case-based uncertainty in the setting of small groups of clinicians.”  Psychologically, such collaboration is apt to confer the benefits of peer support mentioned above.  In addition, it is often more fun and energizing to work as a team, although teamwork can be frustrating at times too.  As a practical matter, putting multiple brains to the task may resolve clinical uncertainties more quickly and/or accurately compared to a practitioner working alone.  Alternative tactics for resolving clinical uncertainty include consulting with recognized experts and conducting literature searches.

In my experience, psychiatrists manage clinical uncertainty by accepting that uncertainty is inherent in the field.  It is therefore not a source of shame or a sign of personal inadequacy.  Released from these emotional burdens, we are free to be curious, to keep an open mind, and to enjoy uncertainty as a puzzle to be solved, an engaging intellectual challenge.  Relatively unstructured dialog in psychotherapy may particularly induce flow states in both participants, with enhanced capacity to accept and work with uncertainty during the hour.  And finally, while many office-based psychiatrists practice individually, social support from peers, supervisors, and treatment teams can enhance comfort with clinical uncertainty.  I have every reason to believe the same holds true in primary care.

Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.

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