Managing Uncertainty

1. Managing Uncertainty Action Within Uncertainty Ontario College of Family Physicians Collaborative Mental Health Care Network Conference 2009

2. 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

3. 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

4. Our Challenge Improve the Signal to Noise Ratio Signal – Usable information Noise – Irrelevant information

5. 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?

6. Research in Uncertainty • Physician Responses to Ambiguous Patient Symptoms J GEN INTERN MED 2005; 20:525–530. • 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.

7. 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 patient’s complete problem. • This may inappropriately narrow the scope of thought and actions.

8. 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

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

10. 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

11. Interaction Risk Symptoms Function

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

13. 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?

14. 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.

15. Framework • Risk • Function • Symptoms

16. Limited Categories Self and Others Intended vs. Unintended Iatrogenic Child safety Motor Vehicle Suicide Homicide Suicide + Homicide Injury Self care Work Financial Maslow’s basic needs Housing, Nutrition, Security Risk

17. The Risk Matrix

18. Function • Personal Care • Child care • Housing • Relationships • Work • Finances • Motor Vehicle

19. The Function Matrix

20. SI HI Hopelessness Command hallucinations Delusions Hallucinations Nihilism Grandiosity Concentration Memory Reasoning Judgment Alcohol use Substance use Insight Impulsivity Prevarication Key Symptoms

21. The Symptom Matrix

22. RISK Symptoms Function SI HI Hopelessness Command Hallucinations Concentration Delusions Hallucinations Memory Reasoning Judgment Alcohol use Substance use Child care Personal Care Motor Vehicle Nutrition Work Self and Others Intended vs Unintended Iatrogenic Child safety Motor Vehicle Suicide Homicide Suicide+Homicide Self care Responsibility Financial Work Housing, Nutrition