Managing Uncertainty

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Managing Uncertainty

• Action Within Uncertainty

Ontario College of Family Physicians
Collaborative Mental Health Care Network
Conference 2009
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Uncertainty

• Although the ascendancy of evidence based
  medicine obscures the uncertainty inherent in
  patient care, this uncertainty remains a defining
  fact of medical life.
• Sandra J Tanenbaum. Commentary Uncertainty,
  consultation, and the context of medical Care BMJ
  VOLUME 330 5 MARCH 2005

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Focus and Clarity

• Focused Attention is challenged by
• Uncertainty, complexity, ambiguity, anxiety, time
  pressure, multiple stimuli
• Managing mental disorders challenges our ability
  to focus and maintain clarity
• No objective investigations
• weave into the fabric of everyday life events.
• Thus information gathering is often overwhelmed
  by a thicket of details

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Our Challenge

• Improve the Signal to Noise Ratio
• Signal Usable information
• Noise Irrelevant information

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Target - Action Plan

• What do I need to do now?
• What do I need to do soon?
• What do I need to pay attention to over time?

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Research in Uncertainty

• Physician Responses to Ambiguous Patient Symptoms
  J GEN INTERN MED 2005 20525530.
• Finding
• Physicians respond to ambiguity by
• Ignoring the ambiguity and becoming more
  directive.
• Patient (describes vague symptoms of general
  chest pain)
• Doctor A Your chest pain is caused by
  gastroesophageal reflux.

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Implications

• When faced with uncertainty, physicians tend to
  impose a diagnosis and then follow with an action
  plan.
• The plan is based on a categorical construct that
  may or may not reflect the patients complete
  problem.
• This may inappropriately narrow the scope of
  thought and actions.

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Goal

• To be able to rapidly organize available
  information into a CLEAR ACTION PLAN.
• Especially in the following cases
• Diagnostic uncertainty
• Complex cases
• Time pressures
• Blind spots

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Objective

• Prioritize Information Gathering
• Risk
• Function (Impairment)
• Key Symptoms
• Improve the Signal to Noise Ratio

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Prioritizing

• Risk
• Its identification and management allows us to
  focus confidently on Functioning and Symptoms
• Function
• Functional status reflects symptom impact and
  points a spotlight on Key symptoms and potential
  risks
• Symptoms
• Clarification of key symptoms illuminates the
  possible conditions and shines the light on
  previously hidden risks and functioning
• Result - Reduce suffering and improve quality of
  life

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Interaction
Risk
Function
Symptoms
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Target Context

• The general office practice
• Multiple issues competing for your attention
• Resource limitations
• Time constraints
• When your anxiety is on the rise

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Target - Action Plan

• What do I need to do now?
• What do I need to do soon?
• What do I need to pay attention to over time?

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Intent

• To increase the likelihood of preventing a
  negative outcome.
• To increase awareness of risks and functional
  impairment.
• To increase confidence in your treatment plans.

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Framework

• Risk
• Function
• Symptoms

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Risk

• Limited Categories
• Self and Others
• Intended vs. Unintended
• Iatrogenic

• Child safety
• Motor Vehicle
• Suicide
• Homicide
• Suicide Homicide
• Injury
• Self care
• Work
• Financial
• Maslows basic needs
• Housing, Nutrition, Security

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The Risk Matrix
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Function

• Personal Care
• Child care
• Housing
• Relationships
• Work
• Finances
• Motor Vehicle

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The Function Matrix
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Key Symptoms

• SI
• HI
• Hopelessness
• Command hallucinations
• Delusions
• Hallucinations
• Nihilism
• Grandiosity

• Concentration
• Memory
• Reasoning
• Judgment
• Alcohol use
• Substance use
• Insight
• Impulsivity
• Prevarication

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The Symptom Matrix
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Self and Others Intended vs Unintended Iatrogenic
Child safety Motor Vehicle Suicide
Homicide SuicideHomicide Self
care Responsibility Financial Work Housing,
Nutrition