In this article Erik Falkum explores the pervasive role of uncertainty in clinical work, emphasizing its heightened presence in psychiatry. Historical and recent coping strategies among medical professionals are discussed, including information-seeking and emotional management. The impact of clinical experience on tolerance for uncertainty is highlighted, along with unconscious coping mechanisms. The Uncertainty-Identity theory is introduced, underscoring how social identification with a group reduces uncertainty but may lead to cognitive closure. The author advocates for addressing uncertainty in clinical training and supervision, deeming it a crucial learning objective for psychiatrists.
The core phenomenon of uncertainty in clinical work
The experience of uncertainty is a core phenomenon in all clinical work. Scientific knowledge about diagnoses and treatment applies to patient groups and is based on probability assessments. It does not necessarily apply to single patients. Whereas uncertainty can be reduced by paraclinical investigations in somatic medicine, decisions in psychiatry most often rely on anamnestic and observational considerations only, meaning that the experience of uncertainty is likely to be more pronounced in psychiatry. It may lead to refusal of decision and action, with potential negative consequences for patients, and is an important source of job stress (Falkum, 2023).
Irony, denial, and changing perspectives
Several decades ago, René Fox (1959, 1980) described how medical students sought to manage their emotional reactions to uncertainty by irony and rough humor, taking a “detached concern” stand to the patient. Twenty years later, Jay Katz (1984) maintained that doctors tended to deny the experience of uncertainty. Today, the idea of patient rights and the “democratization” of medical and psychological knowledge through the internet tend to delegitimize these ways of coping, which are often associated with paternalistic views of the relation between patient and clinician.
Recent research on coping strategies
Recent research has mainly studied how uncertainty can be reduced by collecting more information. Han et al (2021) described four different coping strategies among doctors in internal medicine. The doctors trawled the literature, discussed with experienced colleagues, and ordered additional tests. Furthermore, they focused on the awareness of their insufficient knowledge, which is a prerequisite for the experience of uncertainty as a metacognitive state. Findings were double checked, and a generally high “index of suspicion” colored their job performance. This professional attitude is emotionally demanding and was counteracted by efforts to limit the awareness or by actively recognizing that medical knowledge is never completely certain. The emotional demand was also reduced by delegating responsibility to colleagues.
Awareness, emotional tolerance, and sharing
The third way of coping focused on the physicians’ mental reactions to uncertainty. They sought to tolerate fear and anxiety, reminded themselves of their own professional strengths and tried to cultivate self-forgiveness and resilience when clinical choices turned out to be wrong.
Finally, physicians today more often share their experience of uncertainty with colleagues and are met with support and tolerance rather than condescending reactions. Correspondingly, patients end relatives tend to respond positively when clinicians flag uncertainty and take responsibility for suboptimal treatment results.
Han et al (2021) also described how tolerance for uncertainty increased with the doctors’ clinical experience. Whereas novices tend to view medical knowledge in an either-or perspective, they gradually learned that it is limited and relative, that is, they reached what Hofer (2001) termed epistemic maturity.
The above findings are based on interviews with a small sample of physicians in somatic medicine but are probably as valid in psychiatry. The four ways of coping result from the respondents’ conscious experience. However, there are also several unconscious ways of coping with uncertainty. Some of these have long been addressed in the personal supervision part of specialist training in psychiatry. The psychodynamic tradition’s focus on countertransference and the therapist’s own defense mechanisms partly concerns her way of managing the experience of uncertainty. However, as a fundamental existential feature of the human condition uncertainty has also been addressed in recent cognitive and social psychology.
Kahneman's distinction
Daniel Kahneman’s (2012) distinction between fast and slow thinking sheds important light on the unconscious coping of uncertainty. Our cognitive apparatus contains two “systems”: System 1 operates quickly and automatically and does not produce a feeling of effort or voluntary control. It is operative for instance when we identify rage in a facial expression. System 2, on the other hand, requires attention and mental effort, and produces feelings of concentration, choice, and action. System 2 is operative when we try to understand the source of the rage. System 1 is continuously and automatically active, while system 2 mostly goes to a comfortable low flame. The hectic clinical workday likely often drains the psychiatrists’ system 2, increasing the probability that they accept beliefs that would normally be discarded. System 1 constructs coherent stories based on ideas activated by the associative memory, whilst ideas that are not activated are treated as if they did not exist. Thereby, system 1 reduces the experience of uncertainty, but at the same time it promotes hasty conclusions. Clinical everyday life contains a variety of problematic illustrative examples of this phenomenon.
Uncertainty-identity theory: social sources of coping
An important social source of unconscious coping is described by the Uncertainty-Identity theory (UI theory, Hogg, 2007). It maintains that the need to reduce the experience of uncertainty is a central motive when people identify with various social groups. Increased information reduces the epistemic, but not necessarily the affective dimension of uncertainty, whereas social identification primarily impacts the emotional experience. When we identify with a group of colleagues in an actual scientific or ideological tradition (for example the psychodynamic or cognitive psychotherapy traditions), the group is cognitively represented as a prototype, a category with all the defining characteristics of the group. Thoughts, feelings, and actions of group members are expected to comply with the prototype, which also forms our self-concept. Because group members share their views of the prototype traits, they often confirm and legitimize conceptions, attitudes, and values in each other. When the social identification is strong, it effectively protects against the experience of uncertainty.
Trustful interaction and social identification: reducing uncertainty
The trustful interaction between group members promotes predictability, and the stronger the trust, the stronger the feeling of security. Each single member is expected to act for the good of the group, and if someone has dissenting opinions on important questions, it may entail negative reactions and sometimes isolation and expulsion. This is especially true if dissenting opinions are voiced by central or prototypical members, as illustrated by the expulsion of John Bowlby from the English psychoanalytical society in the nineteen sixties.
As a basically legitimate “strategy” social identification effectively reduces the experience of uncertainty but may also entail cognitive closure (Kruglanski, 2004) and feelings of exclusivity if ambitions of hegemony are prevalent.
Addressing uncertainty in clinical work
The psychiatrist’s tolerance for uncertainty is a central learning objective in specialist training, and in my view, the experience of uncertainty in clinical work should be more thoroughly addressed in both supervision and teaching. The above perspectives on unconscious coping seem particularly important. □
References by request
Falkum, E. (2023). Hva er psykiatri? Om fagets grunnlagsspørsmål. Bergen: Fagbokforlaget.
Fox, R. (1959). Experiment perilous: Physicians and Patients facing the Unknown. Glencoe (IL): Free Press
Fox, R. (1980). The evolution of medical uncertainty. The Milbank Memorial Fund Quarterly. Health and Society. 58(1), 1-49.
Han, P.K., Strout, T.D., Gutheil, C., Germann, C., King, B., Ofstad, E., Gulbrandsen, P., and Trowbridge, R. (2021). How physicians manage medical uncertainty: A qualitative study and conceptual taxonomy. Medical Decision Making, 41(3), 275-291.
Hofer, B.K. (2001). Personal epistemology research: implications for learning and teaching. Educational Psychology Review, 13(4), 353-383.
Hogg, M.A. (2007). Uncertainty-identity theory. Advances in Experimental Social Psychology, 39, 69-126.
Kahneman, D. (2013). Tenke, fort og langsomt. Oslo: Pax forlag.
Katz, J. (1984). The Silent World of Doctor and Patient. New York: Free Press.
Kruglanski, A.W. (2004). The Psychology of Closed Mindedness. New York: Psychology Press.