Friday, August 12, 2011

Getting comfortable with Uncertainty

Medical students are usually taught a rather comprehensive approach to history and physical exam.  They appear to go through a mental check list of all the things that need to be asked and examined.  They start off by following this check list regardless of presentation.  They may also think that a test is needed to rule in or rule out each condition on the differential.  It takes them a while to realize that a good history and physical can diagnose almost 70-80% of unknown cases presenting in the out-patient clinic and that even when one is not sure of the diagnosis, one does not always have to order tests.

When they first show up in clinics students tend to be quite confused that the clinical world is very different from the one they were training for.  The experienced doctor seems to ask questions in a very different order than what they expected and seems to be quite comfortable with uncertainty, tending to order far fewer tests than they would have thought.

What can we do to ease the transition to the clinical years?
Some techniques I have tried are:
  1. I teach a mantra that "Time is a diagnostic tool".  This is particularly true in outpatient medicine.  Some conditions can best diagnosed by waiting and watching.  Either they will go away or they will show new features which will help diagnose them.  
  2. Empiric treatment is also a diagnostic tool.  Sometimes a short course of medication can help - if the condition gets better (or it does not) it can point to the diagnosis.
  3. I give them a framework and ask them to try and place the patients possible diagnoses (from the differential) into one of 3 buckets (categories):
    1. Potentially serious (e.g. life threatening) and urgent (needs to be diagnosed or ruled out quickly)
    2. Potentially serious but not (very) urgent  - this is on a scale 
    3. Likely not serious and not urgent
I then ask them to see if they can eliminate any condition on their differential that falls into category 1.  If that cannot be done, they need to absolutely do some thing right away including ordering a test.  If they can, then they have time and then they can try still order a test or try empiric treatment or wait and watch.

Forcing a student to try and place the likely possible conditions in these categories helps them ask the questions that matter rather than go down a checklist of HPI and ROS and PMH that are often irrelevant.

They students are often confused that they spend a long time with the patient asking questions and doing a head to toe exam and then when the preceptors talk to the patient, they ask one or two pointed questions or check a couple of physical exam findings that change the management completely (see table).  Discussing this with the student early in their clinical rotation can help smooth their transition and reduce their frustration.


Category 1

Category 2

Category 3

Low back pain

Epidural metastases (history of cancer), abscess (Systemic features of infection), (Spine tenderness), (Nocturnal pain)

Sciatica (Straight leg raise test)

Muscle strain (paraspinal tenderness, history of unusual exertion)

Chest pain

Acute coronary syndrome (previous stress test/cath,), aortic dissection  features of affected arteries or nerves e.g horner/recc laryngeal etc)

GERD, viral pericarditis (systemic features, rub, EKG findings)

Rib/muscle strain (reproducible tenderness)


Aneurysm (neuro findings check the pupils disc), Temporal arteritis (age, jaw claudication, eye symptoms, scalp tenderness)

Migraine (photophonophobia, triggers, caffeine)

Scalp hematoma from minor injury

The items in parentheses are just examples of types of questions or exam findings that may not be part of the standard check list that a student my use. These not meant to be inclusive of all such questions. Also there are several guidelines that students can be directed to e.g. the guidelines regarding which head injuries should get a CT scan.

[This is not to say that there is no role for the comprehensive H and P.  Often the students will discover something important about a patient that their primary care provider was unaware of.  This is especially important in someone who has an unresolved symptom/s even after being seen by multiple providers/consultants.  A fresh look at the case with a systematic approach can reveal clues to the answer.

Clinicians will sometimes miss a diagnosis but if the patient is appropriately instructed regarding any red flags and followed closely, the prognosis will usually not be any different.]


  1. Nice post Neil. We should also figure out good ways to help our patients deal with uncertainty.

  2. @Ryan Madanick that is a terrific point. Do you have any special words that you use that help?
    When faced with a possibly serious condition even though the possibility is remote can generate severe anxiety. Depending on the case sometimes when I tell a patient "I don't think this is a cancer or some thing life threatening; but I don't know what it is at this point" they are relieved and prepared to wait before doing multiple more tests.

  3. I'm sharing this with my friends.

    I especially like the bit about the preceptor's 1 or 2 questions after the student had gone through the whole H and P. That killed me for a while.

    Thanks for this post!

  4. @Astupple there is an excellent "old" article from the Annals on "Clinical Hypocompetence" that I find very useful when introducing students to the clinic.

    I wonder if case based teaching and PBL early in the training might make this transition to clinical years easier?