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Navigating Uncertainty
Today we’re talking about a topic that lies at the heart of what it takes to be an expert clinician.
But not only that, this ability has much to do with our levels of stress, feelings of adequacy, and ability to enjoy our jobs.
This concept was introduced to me by a great article that I came across several years ago [1], which put words to a lot of feelings I’d had over the years.
Despite undergoing a lot of education and training, I would sometimes find myself overwhelmed with uncertainty.
It wasn’t just that I wasn’t sure of something. It was the feeling that I had no fucking clue—no idea how to possibly help the person sitting in front of me. The feeling that I shouldn’t be in front of a patient right now. The feeling that all my training had left me unprepared to actually help the person in front of me
Understanding this idea of uncertainty a bit deeper allowed me to see what was happening in those moments. So that instead of pushing away my uncertainty, I could embrace it, or at least let it be there in the room with me without being such a nuisance.
And this is what I want to share with you today, I want us to normalize uncertainty. Because let’s face it—uncertainty is all around us.
In this article, we’re going to talk about:
What I mean by uncertainty and when it tends to show up
The how, what, & why of uncertainty
How to navigate uncertainty so that it can be our friend, not our enemy
Uncertainty is all around us
A 30-year-old male presents to you with low back pain (LBP) of 12 years duration.
Onset was insidious at age 18, around the time that his physical activity levels changed and his parents got divorced.
His symptoms are aggravated with prolonged standing and prolonged walking.
Symptoms are eased with sitting and bending forward.
Other related factors include symptom worsening when he is in a rush or when he doesn’t feel in control of a situation, such as being in a home store with his wife longer than he’d expected to be.
His symptoms have been improving gradually as he has been practicing body awareness in standing, maintaining activity levels, and working on his control issues.
What caused this person’s pain?
Was it the divorce? Changes in activity levels? Faulty movement or posture? Genetics? Personality type? All of the above? None of the above?
The difficulty with causal questions such as this is that it’s impossible to say.
In reality, every single moment leading up to the onset of his pain contributed in one way or another, as all past events are connected in an unbroken chain, one leading to the next.
But the other question that comes up is: Why has the pain been going on for 12 years? What’s perpetuating it?
We could speculate. We could attempt to discover which factors are most salient, but again we find the true answer is elusive.
OK well, what about the diagnosis? What’s the diagnosis?
Is it LBP with movement coordination impairments? LBP with mobility deficits? LBP with cognitive/affective tendencies [4]? Extension-rotation syndrome [5]? Lumbar instability? Hip extension mobility deficits?
If we take on board the fact that the causal chain remains unbroken, meaning that all factors are related to the pain in one way or another, then what diagnostic label will truly suffice? LBP due to being alive? LBP with life coordination impairments?
Choosing a diagnosis with this Truth in mind seems to be based merely on what we can pick up clinically, or what we’re testing for, versus the reality of the situation.
And what are the best treatment options?
Core stability training? Movement re-education? Hip mobility interventions? Lumbar mobility interventions? Stress reduction? Counseling for his control issues? Pain science education? Time?
Our ability to select an intervention depends on our ability to determine what the related factors are, and which of those factors are modifiable.
But which factors are contributing to the pain, and which are merely effects of the pain?
Wouldn’t your activity levels change if you were in pain? Wouldn’t you move differently if you were in pain? Wouldn’t you be stiffer in some areas if you were in pain? Wouldn’t you feel out of control if you had pain that you couldn’t control? Wouldn’t you feel in a rush to sit down if you were in pain while you were standing up?
And what should be done about these things?
If these are merely effects of the pain, will our interventions be enough to break the cycle? Will this person need to keep coming to PT or to keep doing his exercises for life? Why do some people need to do exercises for life and some don’t? Do you do corrective exercises daily? I don’t.
When we ask ourselves questions such as these, we tend to find more questions rather than answers.
And of course, we can—and do—come up with answers. Answers that sound pretty good! But can we really say for sure?
The literature offers us little reprieve, especially when it comes to the diagnosis and treatment of pain, which amounts to more spending than any other health-related issue in this country by far [2].
As much as we may hate to admit it, we’re surrounded by uncertainty in our practice.
And why wouldn’t we be? Uncertainty is part of life.
As much as we’d like to think that we know what’s going to happen in the future, we don’t. Every moment of life is shrouded by mystery. What will happen next? I have no idea. The preeminent meditation teacher, Joseph Goldstein, likes to say, Anything can happen at any time.
How we often deal with uncertainty
So how do we deal with this uncertainty in our practice? How do we show up every day with purpose and move through our days without being overwhelmed by uncertainty?
1. We cling to our models
When things are uncertain, we often seek refuge in systems or models. We might use the ICF classification system published in the Clinical Practice Guidelines by the APTA, Sahrmann’s movement system impairment syndromes (MSI) [5], McKenzie’s MDT, Grey Cook’s SFMA, or one of the many, many other classification models out there.
Staying within the confines of our model makes us feel more certain, that we’re standing on firm ground. And we may trudge forward, treating within these models even if nothing seems to be changing
2. We pass the buck to the patient
When things aren’t unfolding as expected, we often subtly (or not-so-subtly) blame the patient:
They’re just depressed
They haven’t been doing their exercises
Their goals are unrealistic
They’re crazy
Right or wrong, justified or unjustified, it’s clear that passing the buck to the patient is a great way to avoid uncertainty. Instead of saying, I don’t know, blaming the patient is saying, I DO know, but the PATIENT is blowing it
3. We get rid of the patient
If things get too uncertain or the uncertainty goes on for too long, we might just send the patient back to the referring physician, to another provider, or discharge for noncompliance or for failure to improve.
Again, we’re not talking about what the right thing to do is or what the situation calls for. Of course, there are many times where we have good reason to refer the person to another provider or discharge the person. But we can all agree that it is easier to get someone off your schedule than deal with a bucketload of uncertainty.
And this does happen all the time.
The downsides of intolerance of uncertainty
There are very real downsides to the intolerance of uncertainty.
1. It stresses us out
We don’t like feeling uncertain.
But you know what’s worse than uncertainty? Uncertainty + Resistance to uncertainty. Fighting against our uncertainty. Pushing away our uncertainty.
This was exactly what was happening when I would feel utterly useless as a PT earlier in my career. It wasn’t just that I was uncertain, I believed that I shouldn’t be uncertain, so the more uncertain I felt, the shittier I felt, which made me feel more uncertain and even shittier.
I call this the toilet spiral.
This happens because when we push something away, it pushes back. So me pushing against my uncertainty—trying to get rid of it—only made the situation worse.
2. It narrows our view
By attempting to achieve a sense of certainty—especially too soon—we risk something called premature closure in our decision-making process [1]. Which is what it sounds like, coming to a conclusion before really having a good handle on the situation.
Premature closure always involves making assumptions—the antithesis of sound clinical reasoning—and allows our unconscious biases to have more weight than they otherwise would.
So when we cling to our notions of what’s going on, what’s causing this, or what the person needs, we lose our flexibility and adaptability.
We become less curious, less interested in the person’s perspective, less likely to ask for help, and less able to change course when the situation calls for it. All things that we need in order to practice at a high level.
3. The quality of our care suffers
Because we’re stressed, we’re making assumptions, and we’re less curious & nimble with our approach.
Why we cling to black & white
Why do we do this? Why do we push away the grey and cling to the black & white?
1. We’re taught to
In school, we’re taught that there are right & wrong answers. Our professors may not say that, they might even say the opposite, but we are nonetheless conditioned that there are right or wrong answers by:
Multiple choice question tests or other types of tests with right & wrong answers
Grades that tell us how well we’re doing based on these criteria
A general but ubiquitous underemphasis on clinical reasoning, critical thinking, creative thinking in school
We can’t blame it all on The System though. Western culture holds these values dearly, which is probably why our schools are set up in this manner.
2. We don’t like feeling uncertain
Being uncertain instills a sense of vulnerability in us. It’s unsettling and makes us crave the safety of black-and-white answers to escape the greyness of reality [1].
3. We fear not being taken seriously
We fear that by expressing uncertainty, we will project ignorance to our patients and peers. So we instead internalize and mask it [1].
4. It’s easier…
…at least in the short term.
It makes things seem less complicated than they are. It makes things feel more manageable
From a cognitive standpoint, when we classify & categorize, there are fewer data points to remember. Instead of remembering 10 data points, we can just remember that they have extension-rotation syndrome [5] or LBP with movement coordination impairments [4].
From an emotional standpoint, our classifications & categorizations create some space between us & our patients. Instead of facing the reality of the suffering human being sitting before us who's looking to us for help and guidance, it can be much less uncomfortable to view people through the lenses of our classifications & labels.
It’s important to realize that using strategies such as these to avoid uncertainty might be adaptive, but only in the short term.
When we’re first starting out, there’s so much information that it can be totally overwhelming. Using classification systems can be extremely valuable, as we’ll talk about next. But if we continue to view people through narrow lenses and push away our uncertainty, we suffer and our patients suffer.
How to navigate uncertainty
So, if we want to improve our tolerance of uncertainty—or even embrace uncertainty—how can we do this? How can we navigate uncertainty without falling flat on our faces?
1. Have the right attitude
The first and most important aspect of the right attitude to tolerate uncertainty is to be nice to yourself.
When I was in my moments of the toilet spiral, the perpetuating factor was a belief that I need to have all the answers, that I shouldn’t feel uncertain. And when I didn’t have all the answers, I would feel bad about myself, subtly talking shit to myself
If I’ve learned anything from my post-doctorate training and countless hours of mentorship (on both ends), it’s that nobody knows everything.
In fact, those that I respect the most seem to have more questions than answers. But the difference is, they are comfortable not knowing, and they use their questions to collaborate with the patient, to look at the literature, and to look inward.
The wisest among us tend not to have more answers, but rather are more comfortable not knowing.
2. Channel your uncertainty into curiosity
Our uncertainty is telling us something very important. It’s telling us that we don’t know everything.
If we can listen to that voice and be nice to ourselves, it opens us up to curiosity.
We can be curious about the patient’s take on their problem, their ideas about what will help
We can be curious about what research exists on the questions that we have
We can be curious about what our mentors or colleagues might think about the case & any ideas or questions they might have
And of course, we can be curious about what we can do to help this person
Because as uncertain as things may be, we can make a difference
3. Trust that you can make a difference
As bleak as my incessant questioning at the beginning of the article may have painted it, there is much we can do to make a real difference in our patients’ lives.
The importance of embracing uncertainty lies in our ability to work with people without assuming that we know everything.
Because even when our patients get better, we still don’t know why they got better, it could have been anything from our interventions to us listening to them, to us teaching them to pay attention to their body & their life, to the passage of time. Or was it merely their seeking of care; their belief that they can improve with care?
Embracing uncertainty allows us to remain open, flexible, and humble. We are dealing with the human body after all, which is unimaginably complex.
4. Use our classification models, but be able to see through the models
If we try and strip away all of our classifications & models, we may lose the ground that we’re standing on (trust me, I’ve tried).
It’s OK to use these categorizations, heuristics, models. They are useful in their own right.
But we must be able to see the models as what they are— ways of categorizing human beings. Not the human beings themselves. Just as science is our attempt at measuring reality, not reality itself.
So it’s perfectly fine to use Sahrmann’s MSI model to subclassify people with low back pain.
But we must be able to see through the model to see the human being sitting in front of us. And we must be ready to ditch the model when it isn’t serving us or the person in front of us.
And eventually, we will see the model as one filter to look through. One of many, which can be traded for another, layered with others, or removed entirely depending on the situation.
5. Share our uncertainty
I believe it’s important to help our patients navigate uncertainty.
After all, their symptoms don’t bring them in to see us, their concerns about their symptoms bring them in to see us.
And concerns are simply fears of the future.
So if we are to help people suffer less & have less fear (which is what I believe our role as healthcare providers is), we need to help them improve their tolerance of uncertainty.
How do we do this? We model this behavior.
We can use language that supports a dynamic and evolving understanding of the problem.
“My top hypothesis at this point is… Based on… “
“Based on what you’ve told me, here’s what I’m thinking… “
“Based on what we found in the examination, this is what I think will help… “
But this doesn’t mean we can’t be confident & instill confidence in the patient. We can share uncertainty while emphasizing the ground we’re standing on:
“I’ve seen people who present like this and here’s what helped them…“
“Here’s what we do know…“
“We’re going to keep testing, so if things aren’t changing, we won't keep doing the same thing”
“If I can’t help you, I’m going to help you find someone who can…“
The confidence lies in the process.
I’m not confident that all of my patients will get better. I am confident that I can take them through a process that in a relatively short amount of time will help us determine:
Whether they are safe to participate in PT
Whether I can help them (& if not, who can)
That I have a lot of confidence in.
Importantly, you don’t need to constantly share uncertainty with patients.
It’s OK to give simple answers. You don’t need to deep dive into the philosophy of causality every time someone asks you a question. Nor do you need to lead every answer with, "I don’t know."
But there are times when it’s appropriate and important to share the uncertainty of the situation with patients.
When is the appropriate time to do this? It’s uncertain :)
The simple answer: Feel it out. Play around. You’ll figure it out.
What navigating uncertainty is NOT
Navigating uncertainty is not throwing in the towel and declaring that we know nothing.
It is the delicate dance of doing what we can to find the answers we seek while allowing for the inevitability that we will never know everything. An exciting place to be in my view.
This is also not becoming a nihilist, going on Twitter and screaming that everything is crap and that nothing matters.
What we do does matter, even if we’re not always sure why. At the end of the day, if the patient says it matters, it matters.
In Summary
Uncertainty is all around us
We can’t know for sure what caused someone’s pain, what the true diagnosis is (if there is such a thing), or what the best treatment option is
But this is part of life, the only certain thing in life is uncertainty
We often cope with uncertainty by:
Clinging to our assessment or treatment models
Passing the buck to the patient
Discharging the patient
Intolerance of uncertainty:
Stresses us out
Narrows our view
Drags down the quality of our care
We push away uncertainty, clinging to the black & white because:
We’ve been conditioned to think this way
We don’t like feeling uncertain
We fear not being taken seriously
It’s easier (at least in the short term)
Ways to navigate uncertainty include:
Being nice to ourselves
Channeling our uncertainty into curiosity
Trusting that we can make a difference
Being able to see through our classification models, yet still reaping their utility
Sharing our uncertainty with the patient, when appropriate
Having confidence in our process
Thanks for reading!
Andrew
References:
Simpkin, A. L., & Schwartzstein, R. M. (2016). Tolerating uncertainty—the next medical revolution?. New England Journal of Medicine, 375(18).
Gaskin, D. J., & Richard, P. (2012). The economic costs of pain in the United States. The Journal of Pain, 13(8), 715-724.
Croft, P., Dinant, G. J., Coventry, P., & Barraclough, K. (2015). Looking to the future: should ‘prognosis’ be heard as often as ‘diagnosis’ in medical education?. Education for Primary Care, 26(6), 367-371.
Childs, J. D., Cleland, J. A., Elliott, J. M., Teyhen, D. S., Wainner, R. S., Whitman, J. M., ... & Torburn, L. (2008). Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 38(9), A1-A34.
Sahrmann, S., Azevedo, D. C., & Van Dillen, L. (2017). Diagnosis and treatment of movement system impairment syndromes. Brazilian journal of physical therapy, 21(6), 391-399.