‘What do you mean you don’t know?’ Reflections on dealing with uncertainty in healthcare

Emma Ladds, Academic Clinical Fellow, reports from a Pilot Foresight workshop, Monday 25 March 2019, Green Templeton College:

‘So, you’re saying I shouldn’t worry doctor?’ She paused, poised to leave, and turned back to me. ‘You’re saying it’s all ok?’ My frustration soared. We were so close to finishing the difficult consultation. I thought we had found a way through all the uncertainty. But her fear was obvious. I sighed and gestured her back to the chair beside me.

As doctors we are practised at dealing with uncertainty. Patients are complex systems. Make a change and the outcomes are never wholly predictable. Will they take the blood pressure medicines? Will they have an effect? Will they result in a fall? The answers are uncertain and the inevitable loss of control frightening. Although rarely comfortable with this ambiguity, as clinicians we are taught to recognise and minimise uncertainty, constrain its impact and ultimately accept the residual.

Healthcare systems with their intertwined networks, relationships and competing agendas are infinitely more complex than a single patient. The uncertainties are greater, the stakes considerably higher. Add in future ambiguities – changing healthcare systems, external influences, stakeholders and meaningful outcomes, – and the challenges for future healthcare leaders look overwhelming. This is precisely the challenge that Green Templeton’s Foresight programme is poised to address. A pilot event on 25 March 2019 began the first steps of collectively thinking how we may strengthen healthcare leadership to better address these future challenges. An important element will necessarily include better equipping individuals and systems with the wherewithal to understand and work with uncertainty.

There was nothing unusual about my patient that day. She presented with a complaint that initiates over 7% of all primary care consultations: feeling ‘tired all the time’. Only 3% of these cases are ever shown to have a biological cause such as anaemia or hypothyroidism and over 75% are isolated events, suggesting the symptoms resolve on their own. However, for doctor and patient, trying to work out which is more likely for that particular individual, whilst excluding anything serious and accepting the lack of certainty, is a demanding process.

Within such a consultation, I am trained to identify fears – of missing something sinister, of being unwell, and of being out of control with no clear solution. I try and facilitate an acknowledgement of uncertainty; think about investigations or approaches to minimise it; then help individuals develop the confidence and perspective to accept it. Perhaps analogous techniques might be helpful for future healthcare leaders?

Acknowledging the fear generated by uncertainty is crucial. One important example in healthcare leadership is the devolution of power. Relinquishing top-down control reduces the determination of outcomes, increasing overall uncertainty. Ultimately process efficiencies may be greater and outcomes more meaningful thanks to grass-roots engagement and ownership – but you never know, and who will be held accountable?

Changing the balance of probabilities may help constrain these anxieties. In a medical context this is achieved through the application of evidence and investigations. Within leadership, knowledge transference and the use of techniques such as empathy mapping to reduce the likelihood of significantly detrimental responses, achieve analogous roles.

Green Templeton’s Foresight event highlighted a number of possible ways that Green Templeton might help strengthen these approaches for future healthcare leaders. Developing a diverse community of cross-sectoral influential individuals, alongside a repository of intervention case studies demonstrating elements of success and/or failure will aid in this exchange of knowledge.

Enhancing areas of training for future healthcare leaders through a series of seminars, workshops, or even summer programmes for school students could be other effective mechanisms for leadership strengthening. This may include specific techniques such as decision making or empathy mapping. More significant training, generating a basic awareness of the language, issues and principles of different sectors, has potential to better prepare people to form meaningful intersectoral relationships that is likely to promote understanding, constructive dialogue and a willingness to work with uncertainties.

Fundamentally, all leaders have to learn to accept a degree of uncertainty. This is best achieved through the development of resilient systems that are open and flexible, curious, and willing to embrace some of the paradoxes and tensions generated by the unknown. If done effectively, uncertainty may even be reframed as an opportunity rather than liability. Such networks are dependent upon the professional and interpersonal links between the people comprising the system and leaders who recognise the power of relationships and are adequately equipped to form them and support their development between others.

In the end I referred my patient for a neurology opinion. Will this provide the necessary reassurance to enable her to live with her uncertainty? Who knows? I suspect not. However, if our global society is to have the best possible chance of dealing with future health challenges, we must develop leaders and networks that effectively enable systems to engage with uncertainty. Green Templeton could be a constructive and valuable contributor to that development.

Emma Ladds, Academic Clinical Fellow
27 March 2019