Uncertainty in clinical practice: implications for quality and costs of health care

The practice patterns of individual clinicians are fundamental determinants of the quality, ethical standards, and cost-effectiveness of health services. The uncertainties inherent in medical practice are the direct result of biological variability and an enormous range of interchanges between a host of factors. Until recently the uncertainties have been ignored or obscured, but their implications are now being exposed through changes in health service organisation. The implications for the quality and costs of health care are such that it has become mandatory for clinicians, purchasers, and providers to recognise and understand the nature, importance, and influence of uncertainty in determining patterns of action. Paradoxically, it is becoming recognised that power traditionally vested within the health professions, especially doctors, seems to rest as much on uncertainty as on technical expertise.1 Uncertainty has been identified as a major factor common to the key controversies being debated in relation to health-care policy determination.2 More constructive approaches to uncertainty in health care must start with clinicians. For this to happen doctors first need to have a clearer understanding of the causes and impact of uncertainty on their practice and to develop new strategies for responding to it. Clinical decision making is complex, involving intuitive as well as rational thinking. It requires consideration extending beyond the illness or disease in order to take account of value judgments and social, psychological, and moral factors. Although uncertainty is inevitable, clinicians frequently downplay its importance. To some extent this is a defensive reaction taken consciously or unconsciously in response to challenges within an increasingly adversarial environment. Much of the criticism and challenge to traditional attitudes and practice comes from individuals and groups who previously have not been obvious participants in decision making within health services. Unfortunately, the ways in which clinicians respond to uncertainty and questioning of their practice may have adverse effects on complex decision-making processes,3 leading, for example, to unnecessary overinvestigation of patients in the desire to reduce diagnostic uncertainty to a minimum. Katz4 has gone so far as to say that the doctorʹs defences against ignorance and uncertainty are a greater difficulty in the physician-patient interaction than the patientʹs ignorance.