Managing Variability and Uncertainty

Definitions

If ignorance is defined as an absence of knowledge of the available issues or options as well as of their probability, uncertainty is defined as knowledge of the issues or options available but with an absence of the knowledge of their probability. Risk is the concept of variability is distinguished from that of uncertainty and refers to the heterogeneity of subjects included in analyses. Although the distinction between variability and uncertainty has clear implications from a decision analysis perspective, for clinicians and their patients, variability is only one of the many sources of uncertainty.

Physicians' Reaction to Uncertainty

Both patients and their physicians have difficulty grasping the concept of uncertainty, specifically when dealing with numbers and probabilities. Physicians express concerns with communicating risk to patients and may not have the necessary [Page 692]skills to do it. In brief, the medical problem and the characteristics of the patient create the uncertainty inherent in the clinical encounter. The characteristics of physicians influence their reaction to uncertainty. In turn, the decision-making process occurring during the clinical encounter between a patient and a physician is under the influence of the uncertainty inherent in the clinical encounter and of the physician's reactions to uncertainty. Patients and physicians interact to produce a set of decisions that in some cases will be translated into physicians' behavior. The decision outcome and, on some occasions, the physician's behavior may be modified by external sources such as source of payment, setting of the practice, and so on. The reaction of physicians to uncertainty is composed of four main constructs: anxiety due to uncertainty, concern about bad outcomes, reluctance to disclose uncertainty to patients, and reluctance to disclose mistakes to other physicians. The reaction of physicians toward uncertainty was shown to be significantly associated with disclosure of uncertainty by physicians to patients during clinical encounters, resource use and costs, and the intention of physicians to engage in shared decision making. Therefore, strategies to alleviate the burden of managing uncertainty in clinical decision making are of utmost importance in ensuring quality of care, patient safety, and control of costs for the healthcare system.

...