{"id":910,"date":"2014-05-08T00:08:07","date_gmt":"2014-05-08T07:08:07","guid":{"rendered":"http:\/\/blog.stevenreidbordmd.com\/?p=910"},"modified":"2014-05-08T06:51:49","modified_gmt":"2014-05-08T13:51:49","slug":"enjoying-clinical-uncertainty","status":"publish","type":"post","link":"http:\/\/blog.stevenreidbordmd.com\/?p=910","title":{"rendered":"Enjoying clinical uncertainty"},"content":{"rendered":"

\"Uncertainty-is-an-uncomfortable\"<\/a>Lucia Sommers of the Department of Family and Community Medicine at UC San Francisco commented<\/a>\u00a0on my last post, noting that clinical uncertainty among primary care physicians (PCPs) is usually regarded as tolerable at best. \u00a0She was delighted that I called such uncertainty intellectually attractive,\u00a0and something to embrace in psychiatry.\u00a0 Sommers and her coauthor John Launer recently published a\u00a0book<\/a> that argues for managing clinical uncertainty in primary care using “collaborative engagement with case-based uncertainty in the setting of small groups of clinicians.” \u00a0This contrasts with medicine’s tradition of practitioners working independently. \u00a0In her comment, Sommers asked me to describe\u00a0how psychiatrists manage clinical uncertainty, and specifically whether “supervision” \u2014 cases “presented for discussion to at least another psychiatrist if not a small group,” similar to what she advocates for primary care physicians \u2014\u00a0is a good strategy in my experience. \u00a0This post is my\u00a0response.<\/span><\/p>\n

At its most fundamental level, human psychology exists to manage uncertainty. \u00a0Confronted with an incomprehensible, threatening world, the infant soon differentiates “good” from “bad.” \u00a0Initially a crude split without\u00a0nuance or shades of gray, this primitive\u00a0psychological distinction, \u00a0second\u00a0only to distinguishing\u00a0“self” from\u00a0“other,” represents\u00a0a huge step forward. \u00a0It sets\u00a0the stage for approach versus avoidance \u2014 the first “management” the infant undertakes. \u00a0Further psychological development allows subtler gradations to improve upon\u00a0this harsh dichotomy. \u00a0Developmental psychology\u00a0describes how secure attachment with caretakers, and an increasingly stable sense of self, contribute to tolerance of uncertainty. \u00a0With\u00a0normal development, and under\u00a0most circumstances, we no longer cling desperately to\u00a0sharp black-or-white categories. \u00a0We make finer distinctions, and can also\u00a0tolerate degrees of uncertainty.<\/p>\n

Adult development takes this process further. \u00a0Mastery of an academic or occupational field solidifies\u00a0a\u00a0stable professional\u00a0identity, which contributes to comfort with uncertainty. \u00a0Many years ago I learned a type of computer programming from my friend, an accomplished software engineer. \u00a0I felt anxious when confronted with programming challenges: \u00a0Would I fail to discover the solution? \u00a0Waste long hours trying? \u00a0Feel stupid in the end? \u00a0In contrast, my friend felt\u00a0no such anxiety. \u00a0He explained that even when\u00a0he was uncertain how<\/em> to solve a problem, he knew\u00a0he soon\u00a0would<\/em>, or at least would soon recognize it was impossible. \u00a0He was able\u00a0to wrap his arms around the whole field in a way I could not. \u00a0Uncertainty for him no longer carried implications of permanence, nor of personal failure, i.e.,\u00a0\u00a0narcissistic injury. \u00a0It wasn’t threatening. \u00a0In this frame of mind, a programming challenge is merely a puzzle, an engaging intellectual pursuit which\u00a0can even be\u00a0fun.<\/p>\n

Although the stakes are higher, the same applies\u00a0in medicine. \u00a0An intern faced with clinical uncertainty shares my erstwhile self-doubt as a beginning computer programmer. \u00a0Is my uncertainty humiliating? \u00a0A sign of failure? \u00a0Will I ever figure it out? \u00a0With more experience comes confidence that uncertainty isn’t psychologically threatening. \u00a0It’s an intellectually engaging puzzle, often with a\u00a0gratifying\u00a0emotional reward at the end. \u00a0In specialties such as primary care and psychiatry, uncertainty becomes the norm. \u00a0We get used to it, expect it; we\u00a0realize it doesn’t tarnish\u00a0us individually.<\/p>\n

An additional factor that may sound esoteric\u00a0but is crucial to thriving in uncertainty is the flow state<\/a>. \u00a0Variously 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\u00a0accompanied by\u00a0a relative lack of self-consciousness and conscious intent. \u00a0Whether in extreme sports, music improvisation, video gaming, or academic brainstorming, moment-by-moment uncertainty\u00a0is\u00a0less disruptive and feels more welcome in the flow state. \u00a0Although uncommon\u00a0in typical\u00a0medical practice, the flow state\u00a0can arise\u00a0during\u00a0intimate discussion with a patient, during research activities, and when intensely absorbed in medical work-up or treatment planning \u2014 the very times when clinical uncertainty is actively addressed.<\/p>\n

Peers\u00a0are\u00a0a good source of emotional support whatever one’s level of expertise. \u00a0Seeing that a\u00a0problem is inherently difficult is reassuring; its apparent difficulty does not\u00a0reflect on oneself. \u00a0Social interaction bolsters self-esteem, and often humor is shared to defuse fear and anxiety. \u00a0Similar challenges shared by others promote camaraderie and a sense of being “all in the same boat.” \u00a0And tales of challenges successfully overcome can instill optimism, and sometimes offer practical solutions for the problem at hand.<\/p>\n

My own experience with psychiatric supervision is hierarchical, not peer-to-peer. \u00a0Supervisors model a great deal non-verbally and often unintentionally: our\u00a0attitudes toward patients and their issues, the focus of clinical attention, our\u00a0approach to formulating cases, levels of formality and informality, and so on. \u00a0The supervisor’s engagement with clinical uncertainty is one such factor, sometimes discussed explicitly, more often modeled non-verbally. \u00a0Ideally,\u00a0this role-modeling inspires and encourages supervisees to nurture clinical\u00a0curiosity, and to avoid frantic efforts to resolve uncertainty with premature conclusions.<\/p>\n

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.” \u00a0Psychologically, such collaboration\u00a0is apt to confer the benefits of peer support mentioned above. \u00a0In addition,\u00a0it is often more fun and energizing to work as a team, although teamwork can be\u00a0frustrating at times too. \u00a0As a practical matter, putting multiple brains to the task may resolve clinical uncertainties more quickly and\/or accurately compared to\u00a0a practitioner working alone. \u00a0Alternative tactics for resolving clinical uncertainty include consulting with recognized experts\u00a0and\u00a0conducting literature searches.<\/span><\/p>\n

In my experience,\u00a0psychiatrists manage clinical uncertainty by accepting\u00a0that uncertainty is inherent in the field. \u00a0It is therefore not a source of shame or a\u00a0sign\u00a0of personal inadequacy. \u00a0Released from these emotional burdens, we are free to be\u00a0curious, to keep an open mind, and to enjoy uncertainty as a puzzle to be solved, an engaging intellectual challenge. \u00a0Relatively unstructured dialog in psychotherapy may particularly induce flow states in both participants, with enhanced capacity to accept and work with uncertainty during the hour. \u00a0And finally, while many office-based psychiatrists practice individually, social support from peers, supervisors, and treatment teams can enhance comfort with clinical uncertainty. \u00a0I have every reason to believe the same holds true in\u00a0primary care.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

Lucia Sommers of the Department of Family and Community Medicine at UC 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 coauthor […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[34,7],"tags":[43],"class_list":["post-910","post","type-post","status-publish","format-standard","hentry","category-human-nature","category-psychiatric-diagnosis","tag-uncertainty","odd"],"aioseo_notices":[],"_links":{"self":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/910","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=910"}],"version-history":[{"count":6,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/910\/revisions"}],"predecessor-version":[{"id":917,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=\/wp\/v2\/posts\/910\/revisions\/917"}],"wp:attachment":[{"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=910"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=910"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/blog.stevenreidbordmd.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=910"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}