Types of uncertainty

  • Teacher
  • Patient
  • Doctor/Registrar
  • Knowledge
  • Diagnosis
  • Management
  • Treatment
  • Agenda (overt/hidden)
  • Shared Uncertainty – with patient
  • Resources
    • Can we implement plans?
  • Business
    • Organisation
    • Finance

Concept of the ‘safety-net’ is essential

Uncertainty in the doctor depends on several aspects

  • Knowledge
  • Support
  • Confidence
  • How much uncertainty can we tolerate?
  • Use of time
  • Overkill (too many tests, etc.)

Dealing with uncertainty

  • Treatment & management
    • Increased number of tests
    • Second opinions
    • Use of time
    • Safety netting
  • Treatment
    • Second opinions
    • Increased knowledge
    • Keeping up to date
    • Alternative options
  • Management
    • Sharing patient’s agenda
    • Health beliefs
    • Negotiation
    • Explanation
    • Identifying and dealing with the patient’s actual problem
    • ‘Playing God’ (prioritising)

Example: dealing with the scenario of 12-year-old girl with discharge

  • Issues
    • Why the uncertainty
    • How to broach a sensitive area
    • Worry about getting out of depth – opening a ‘can of worms’
  • Duties of a doctor
  • Practical
    • Who do you turn to?
    • Where does the knowledge come from?
    • Technical competence
  • Social/Personal – Home v Work
  • Ethical
    • Personal
    • Patient
    • Family
    • Society
  • Limiting Risk – Doctor and Patient
  • Use of time
  • Exploring possibilities


  1. Support mechanism – the Registrar must be aware what support is available and how to access it.
    This should be provided when the Registrar arrives at the practice so they can know what is available and how to access it.
  2. Recognition of limitations.
  3. Recognition of ‘key triggers’.
  4. Identify minimum competency/strategy.
  5. Acknowledge uncertainty and share it.
    This is an integral part of dealing with a Registrar’s uncertainty. It is important for them to appreciate we all have uncertainty within consultations. The difference is more experienced doctors are better able to cope with this uncertainty and have a high threshold before distance appears. Factors which influence this are knowledge, skills, experience, etc.

Aspects to consider when teaching

  • Why the uncertainty? – Identify the problem.
  • Acknowledge the uncertainty (it’s OK to be that way).
  • Shared understanding.
  • Look at the problem from different perspectives (doctor/patient etc.). Try to triangulate.
  • Consider alternative strategies.
  • Resources
  • Existing resources
    • Modelling
    • Experience
    • Find other resources/potential solutions
  • Agreed management
  • Safety net
  • Review (have we learned/managed the uncertainty?)


  • Dissonance
  • ‘Safe insecurity’
  • Keep the discomfort tolerable
  • Challenge gently/appropriately
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