Uncertainty, consultation, and the context of medical careBMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7490.515 (Published 03 March 2005) Cite this as: BMJ 2005;330:515
- Sandra J Tanenbaum (), associate professor1
- 1 School of Public Health, Ohio State University, 246 Atwell Hall, 1583 Perry Street, Columbus, OH 43210, USA
Although the ascendancy of evidence based medicine obscures the uncertainty inherent in patient care, this uncertainty remains a defining fact of medical life. Griffiths et al listened to health professionals and identified three distinct approaches that were used in consultations—two of which they judged to understate the risk level of patients.1 They recommend that health professionals should be trained to communicate with their patients without recourse to the myth of medical certainty.
The authors produced a distribution of approaches to consultation across several health professionals, settings, and health issues, and draw some intriguing inferences. Their findings also generate further research questions, especially about the relation between the context of medical care and the strategies used by health professionals in consultations. The potential to improve the communication of risk through training may be mitigated by factors external to the doctor-patient relationship—specifically, by extra clinical functions of the healthcare system. For example, in the case of mammography and other types of screening, where patients' anxiety levels are often high, the troublesome “certainty for now,” approach is surely an attempt to reassure the patient, as suggested by Griffiths et al. This reassurance may, in fact, ameliorate a difficult situation for both the patient and the health professional. It is possible, moreover, that the promise of certainty (and in most cases, relief) motivates women to have the screening at all. Assuming that doctors (and health officials) seek to encourage women to undergo mammography, might not they be offering the security of knowing as a reward for the anxiety (and for some, discomfort or expense) of the test? In other words, the choice of an unsatisfactory approach to consultation might be strategic from a population health perspective. This particular rhetoric of uncertainty may serve to bring women to the consulting room in the first place.
Again, as the authors point out, continuous access to general practitioners seems a condition for the preferred “acknowledging uncertainty” approach to risk communication. The study data indicate, however, that whereas general practitioners use non-optimal strategies as often as they “acknowledge uncertainty,” they are more likely to acknowledge this uncertainty in the consultations for reviewing use of hormone replacement therapy or restarting the therapy after a break. Why, then, is periodic review conducive to acknowledging uncertainty when periodic screenings apparently are not? It is possible that the distributional implications of the test results of screening lead both doctors and patients to vest them with greater certainty. Screening sorts patients into categories—not only for treatment planning but also for the allocation of scarce healthcare resources. Screening, in other words, serves as a gatekeeper in many healthcare systems and legitimises the distribution of medical care among patients whose actual medical condition is in some ways unknowable.
Griffiths et al suggest many avenues for further investigation. A contextual focus, shared by the research questions above, might discover that the communication of uncertainty is shaped by the functions of the larger healthcare system. This would complicate, but by no means obviate the need for, the training of health professionals to talk about risk.
Competing interests None declared.