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Analysis

Hospitalists Well-Positioned to Manage Clinical Uncertainty

By Christopher Cheney  
   July 06, 2018

Uncertainty plays a key role in wasteful healthcare decisions such as ordering unnecessary medical tests, and hospitalists can help address the problem in their role as educators.

Uncertainty is a primary driver of wasteful clinical care in the hospital setting, researchers say.

Even though the Choosing Wisely campaign has generated more than 500 guidelines to decrease unnecessary testing and treatment, hospitalists face many other uncertainties daily, the researchers wrote in an article published in the Annals of Internal Medicine.

"Guideline recommendations cannot possibly cover the range of decisions that hospitalists make on a daily basis. This gap leaves large areas of uncertainty that are often filled with unnecessary care," they wrote.

They say uncertainty fuels misguided decision-making about medical testing. "An unfortunate consequence of uncertainty is that it often leads to a knee-jerk reflex to 'order more tests' and, in many cases, the additional tests do not significantly reduce the uncertainty at hand."

Unnecessary testing linked to uncertainty has multiple negative impacts, they wrote.

"This seemingly innocuous search for clarity is a likely contributor to the estimated $25 billion waste related to the misuse or overuse of medical testing. Uncertainty has also been shown to result in unnecessary referrals, increased admission rates, delays in patient care, and even patient harm."

Hospitalists key players

Hospitalists are well-positioned to limit the impact of uncertainty, says Charlie Wray, DO, MS, lead author of the uncertainty article and an assistant professor at the University of California San Francisco.

Hospitalists are at the front-lines of inpatient education and teaching, which gives them a crucial role in teaching the next generation of physicians, Wray told HealthLeaders this week.

"This gives hospitalists the ability to role model and show our trainees that it's OK to not always have the exact right answer or to be uncertain of a decision."

Wray and his coauthor cited three approaches hospitalists can take to limit the impact of uncertainty:

  • Use the Physicians' Reaction to Uncertainty tool, which measures a clinicians' response to uncertainty. Using this tool at the beginning of a rotation can quantify uncertainty, allowing a hospitalist to acknowledge it and to discuss how uncertainty could affect testing decisions.
     
  • Use a learning tool such as SNAPPS to help clinicians express uncertainty during daily rounds. Expressing uncertainty is often frowned upon in medical culture, which places a premium on knowing the correct answer. A singled-minded focus on correct answers encourages learners to ignore uncertainty rather than finding out how to manage it.
     
  • Patient engagement and shared decision-making are essential because of patient unease over uncertainty. Discussions with patients should include acknowledging the vagaries of clinical care as well as the potential harms and benefits of tests.

Engaging patients openly and honestly is crucial because many of them have "therapeutic illusions" that overestimate the value of testing and underestimate the potential for harm, Wray says.

"I've found that when we're honest with our patients about the limitations of medicine, the therapeutic illusions they may have brought to the situation easily fade away as they come to understand what medicine can, and cannot, do for them. In having this open and patient-centric conversation, you build a report with the patients."

Wray has developed an approach for these kinds of conversations with his patients.

"I will be extremely focused on what our plan is. For instance, I will say we will do this if X happens, and we will do that if Y happens. Getting specifics, having a contingency plan, and knowing the direction of their care is always comforting to patients."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


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