Managing Managing UncertaintyUncertainty

Action Within UncertaintyAction Within Uncertainty

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

UncertaintyUncertainty““Although the ascendancy of evidence Although the ascendancy of evidence

based medicine obscures the based medicine obscures the uncertainty inherent in patient care, uncertainty inherent in patient care, this uncertainty remains a defining this uncertainty remains a defining fact of medical life.”fact of medical life.”

Sandra J Tanenbaum. Sandra J Tanenbaum. Commentary: Uncertainty, consultation, and Commentary: Uncertainty, consultation, and the context of medical Care BMJ the context of medical Care BMJ VOLUME 330 5 MARCH 2005VOLUME 330 5 MARCH 2005

Focus and ClarityFocus and Clarity Focused Attention is challenged byFocused Attention is challenged by

Uncertainty, complexity, ambiguity, anxiety, Uncertainty, complexity, ambiguity, anxiety, time pressure, multiple stimulitime pressure, multiple stimuli

Managing mental disorders challenges Managing mental disorders challenges our ability to focus and maintain clarityour ability to focus and maintain clarity No objective investigationsNo objective investigations weave into the fabric of everyday life events. weave into the fabric of everyday life events.

Thus information gathering is often overwhelmed Thus information gathering is often overwhelmed by a thicket of detailsby a thicket of details

Our ChallengeOur Challenge

Improve the Signal to Noise Improve the Signal to Noise RatioRatio

Signal – Usable informationSignal – Usable informationNoise – Irrelevant informationNoise – Irrelevant information

Target - Action PlanTarget - Action Plan What do I need to do now?What do I need to do now? What do I need to do soon?What do I need to do soon? What do I need to pay attention to What do I need to pay attention to

over time?over time?

Research in UncertaintyResearch in Uncertainty Physician Responses to Ambiguous Physician Responses to Ambiguous

Patient Symptoms Patient Symptoms J GEN INTERN MED 2005; 20:525–J GEN INTERN MED 2005; 20:525–530.530.

FindingFinding Physicians respond to ambiguity by: Physicians respond to ambiguity by:

Ignoring the ambiguity and becoming more Ignoring the ambiguity and becoming more directive. directive.

Patient: Patient: (describes vague symptoms of (describes vague symptoms of general chest pain)general chest pain)

Doctor A: Doctor A: Your chest pain is caused by Your chest pain is caused by gastroesophageal reflux.gastroesophageal reflux.

ImplicationsImplications When faced with uncertainty, When faced with uncertainty,

physicians tend to impose a diagnosis physicians tend to impose a diagnosis and then follow with an action plan.and then follow with an action plan.

The plan is based on a categorical The plan is based on a categorical construct that may or may not reflect construct that may or may not reflect the patient’s complete problem.the patient’s complete problem.

This may inappropriately narrow the This may inappropriately narrow the scope of thought and actions.scope of thought and actions.

GoalGoal To be able to rapidly organize To be able to rapidly organize

available information into a available information into a CLEAR CLEAR ACTION PLANACTION PLAN.. Especially in the following cases:Especially in the following cases:

Diagnostic uncertaintyDiagnostic uncertainty Complex casesComplex cases Time pressuresTime pressures Blind spotsBlind spots

ObjectiveObjective1.1. Prioritize Information GatheringPrioritize Information Gathering

1.1. RiskRisk2.2. Function (Impairment*)Function (Impairment*)3.3. Key SymptomsKey Symptoms

Improve the Signal to Noise RatioImprove the Signal to Noise Ratio

PrioritizingPrioritizing1.1. RiskRisk

Its identification and management allows us to focus Its identification and management allows us to focus confidently on Functioning and Symptomsconfidently on Functioning and Symptoms

2.2. Function Function Functional status reflects symptom impact and points a Functional status reflects symptom impact and points a

spotlight on Key symptoms and potential risksspotlight on Key symptoms and potential risks

3.3. SymptomsSymptoms Clarification of key symptoms illuminates the possible Clarification of key symptoms illuminates the possible

conditions and shines the light on previously hidden risks conditions and shines the light on previously hidden risks and functioningand functioning

Result - Reduce suffering and improve quality of Result - Reduce suffering and improve quality of lifelife

InteractionInteraction

Risk

Function

Symptoms

Target ContextTarget Context The general office practiceThe general office practice

Multiple issues competing for your Multiple issues competing for your attentionattention

Resource limitationsResource limitations Time constraintsTime constraints When your anxiety is on the riseWhen your anxiety is on the rise

Target - Action PlanTarget - Action Plan What do I need to do now?What do I need to do now? What do I need to do soon?What do I need to do soon? What do I need to pay attention to What do I need to pay attention to

over time?over time?

IntentIntent To increase the likelihood of To increase the likelihood of

preventing a negative outcome.preventing a negative outcome. To increase awareness of risks and To increase awareness of risks and

functional impairment.functional impairment. To increase confidence in To increase confidence in

your treatment plans.your treatment plans.

FrameworkFramework RiskRisk FunctionFunction SymptomsSymptoms

RiskRisk 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

The Risk MatrixThe Risk MatrixRiskRisk SelfSelf OthersOthers

IntendedIntended

UnintendedUnintended

IatrogenicIatrogenic

FunctionFunction Personal Care Child care Housing Relationships Work Finances Motor Vehicle

The Function MatrixThe Function MatrixFunctionFunction SelfSelf OthersOthers

PersonalPersonal

ProviderProvider

PrivilegesPrivileges

PPre-relationalre-relational

Key SymptomsKey Symptoms SI HI Hopelessness Command

hallucinations Delusions Hallucinations Nihilism Grandiosity

Concentration Memory Reasoning Judgment Alcohol use Substance use Insight Impulsivity Prevarication

The Symptom MatrixThe Symptom MatrixSymptoSymptomsms

CognitiCognitiveve

EmotioEmotionalnal

SensorSensoryy

BehaviouBehaviouralral

ExpressExpressededReporteReporteddObservObserveded

SuspectSuspecteded

SIHIHopelessnessCommand HallucinationsConcentrationDelusionsHallucinationsMemoryReasoningJudgmentAlcohol useSubstance use

RISK

SymptomsFunction

Child carePersonal CareMotor VehicleNutritionWork

Self and OthersIntended vs UnintendedIatrogenic

Child safetyMotor VehicleSuicide HomicideSuicide+HomicideSelf careResponsibilityFinancialWorkHousing, Nutrition