What do you do when you don’t know what to do? (WDYDWYDKWTD)

“So what is the key message?”

This question cropped up during the discussion after a webinar about uncertainty in medical practice. Uncertainty is complex, pervasive and occurs in almost every consultation. So what is the key thing to remember?

Uncertainty feels very uncomfortable for clinicians, it makes them feel as if they are likely to get something wrong, to make a mistake, to be in error, because the way forwards is not clear. This discomfort can be so bad that clinicians try to escape it immediately by jumping to a decision. This could be by using pattern recognition (“this seems like another case of the flu that’s going round”) or by reflex actions (” this is tricky I will just refer on”). However, aiming for certainty all the time is fraught with difficulties. Doctors who are sued or referred to the GMC are sometimes surprised that the people who complain seemed ordinary and straightforward at the time….the clinician didn’t get a sinking feeling or a WDYDWYDKWTD moment. This may happen when allowing for uncertainty  seems too difficult, so the clinician immediately jumps away into some kind of comforting certainty about what to do next.

It follows that we need to notice uncertainty, value uncertainty and allow it to be an “inner alarm bell”.  Being uncertain need not be thought of a deficiency in the clinician, or as a fault in itself. Uncertainty is a guide, a reminder, to take a little time to reflect and ask oneself some questions.

“What is really going on here? Is this a problem with the diagnosis? Or is it a problem with how I am approaching the management of this problem?”

This pause for reflection should then allow the clinician to choose which skill might be most helpful. If there is a diagnostic problem it may be about creating the right hypothesis using basic clinical reasoning, or it may be thinking more clearly along the lines of “am I trying to rule something IN here or trying to rule something OUT?” and ensuring that the process is explained clearly in a dialogue with the patient.

If there is an issue about managing a known diagnosis, then it may be that specific negotiating skills are required (“what does this individual person need and want right now?), or, it may be about coordinating the activities of several team members…which is s skill in itself!.

So the key message is to notice and accept uncertainty and use it as a guide for reflection. Then ask “what kind of problem is this and what kind of skill will I need to solve it?”.  Expert practitioners do this kind of thinking rapidly, and may not explicitly explain how they were thinking…..so it seems to outside observation that they “just know what to do”. In fact, they probably noticed something uncertain, that didn’t seem quite right, paid attention to it and worked out what was needed next.