Dealing with uncertainty

I have recently become interested in the concept of uncertainty, particularly as it relates to remote clinical practice.  Uncertainty is a normal part of human existence, and very often it is an uncomfortable part.  People tend to try to minimise uncertainty, to reduce the discomfort it causes.  This occurs in a number of ways, and these have consequences for the safety and quality of clinical practice.

• Avoidance is a common technique.  It involves manipulating the environment to eliminate or at least reduce the amount of uncertainty.  For example, a nurse who lacks confidence in dealing with children will avoid working in paediatrics, as this reduces the uncertainty he or she feels in this setting.  In a remote setting, this nurse may have no choice but to deal with children, and attempts to avoid doing so will have consequences for the health care team.
• Denial is also common.  Uncertainty can be denied by simply ignoring the fact that it exists, and seeing all issues as black and white.  For example, if a patient is labelled as a drunk, there is no uncertainty about inconvenient differential diagnoses such as subarachnoid haemorrhage or hypoglycaemia.  The consequences for denial are obvious, and mostly stem from corrupting the evidence base for quality clinical practice.  If you ignore relevant alternatives, you do reduce uncertainty, but also increase the risk of being wrong.  Being wrong in clinical practice is typically detrimental to patients.
• Logic can be used to try to reduce uncertainty.  Evidence is collected and weighed, and used to make a decision about a course of action.  The more comprehensive this process, the more valid the outcomes.  However, it requires time and effort, both of which can be in short supply at times.  There will always be another possibility that 'should have been considered', and the weighing of evidence is itself fraught with bias and uncertainty.  Logic and reasoning are valuable tools, and should certainly be used, but they do not eliminate uncertainty.  I'm not sure they even reduce it!
• Dogma is another all-too-common approach to uncertainty.  For millenia, humans have sought explanations for things they do not understand, and religion has evolved to meet this need.  By attributing the unknown, and often also the known, to an omnipotent omnipresent diety, uncertainty is eliminated by stating that it is 'God's will' or the 'will of Allah' or whatever.  Uncertainty then becomes evidence of a lack of faith, so the 'faithful' strenuously pretend to be certain of what they claim to believe.  Unfortunately, this does nothing to actually reduce uncertainty, and in fact makes it worse by pushing it underground.  In clinical practice, dogma is detrimental to safety and quality, as it absolves practitioners from responsibility for decisions - after all everything is 'in God's hands'.
• Probably the least common approach to dealing with uncertainty is acceptance.  By accepting that uncertainty is normal and expected, practitioners can allow for the fact that they will make mistakes sometimes.  Reducing mistakes is part of professional development, but it is unreasonable to expect that they can be eliminated.  

I think the reality for most practitioners is that they use a bit of everything.  A dash of avoidance, a hint of denial, a cup of logic, a pinch of religion, and top up with acceptance.  The important thing is to be reflective and know what your coping mechanisms are.  This allows the practitioner to assess whether their approach contributes to or detracts from safety and quality.

Thinking by proxy

At my workplace we have recently implemented the Modified Early Warning Score (MEWS) to assist clinicians to decide if their patients are unwell or not.  On the surface of it, you would think this is a great idea, especially as it empowers junior staff to call senior staff to review patients they are concerned about.  Given my interest in the role or rational thinking in healthcare, my view is less positive.

I have no problem with the MEWS being used as a tool to quantify your concern about a patient, even though there are times when you are concerned despite the observations appearing OK (and hence the MEWS is OK).  What I have serious doubts about is staff using MEWS to decide whether they should be concerned!!  If you need a score on a sheet of paper to decide if your patient is unwell, you probably should find another line of work.

Using the MEWS in the Emergency Department makes no sense.  It merely adds another task to the list, with little likelihood of impacting on patient outcomes.  This is especially true when there are no policies in place to govern the use of MEWS in this setting.  Say a patient has a MEWS of 8, so what?  We will already be implementing emergency care to deal with whatever the problem is, so what are we adding to the equation?  If the MEWS is supposed to guide the level of response such as Triage Category, them I'm getting really worried.  Allocating triage categories and directing ED resources is a specialised skill, and should not be done by inexperienced staff, so I can't see how using MEWS is going to improve anything in the ED.

However, because someone higher up the food chain than the frontline staff has decided that MEWS is the best thing since sliced bread, it seems that it is here to stay.  Its use is even being audited, which is quite funny is a sad way.  Since it has no bearing on patient outcomes in the ED, auditing its use is a waste of resources.  If we're going to audit it at all, we should audit its efficacy not just whether it is being used!!