Uncertainty is the conscious awareness of being unsure, having doubt, or not fully knowing. Medical decision making by nature occurs in the setting of various levels of uncertainty. Uncertainty in medicine is categorised into aleotoric (chance uncertainty), and epistemic (limitations in knowledge). These two types of uncertainty tend to occur together. They have a direct impact on diagnostic error, as premature closure can lead to misdiagnosis.
Aleatoric uncertainty is chance uncertainty. It includes uncertainly due to variability in disease processes between people, disease incidence, outcomes, and personal significance of particular risks.
Epistemic uncertainty is uncertainty due to the limitations of medical knowledge and limitations in the doctors ability to access (e.g. limited access to medical literature) and process existing medical knowledge. It also includes uncertainty from translating population level findings to individuals, and uncertainty from complex or poorly understood evidence.
If the doctor does not have their own already formed illness scripts, then they can compare the patients presentation to illness scripts from medical literature.
If a diagnosis is not able to be made, Dhaliwal says the doctor asks themselves the following questions:
- Have I reached the limit of my knowledge but not that of my colleagues?
- Have I reached the limits of my local network’s knowledge but not that of another physician or team elsewhere?
- Have I reached the limits of medical knowledge entirely (i.e., there is no known answer to the problem)?
Due to the proliferation of information sources and diagnostic possibilities, for which Musculoskeletal Medicine is no exception, the endpoint is ambiguous. At what point is the presentation labelled idiopathic. At what point do you stop investigations. In Musculoskeletal Medicine, often the barrier is funding (such as ACC) rather than the desire of the patient and doctor to keep searching.
- Rendon P, Roesch J, Dhaliwal G. The Writing on the Wall: An Exercise in Clinical Reasoning. J Gen Intern Med. 2020 Aug;35(8):2462-2466. doi: 10.1007/s11606-020-05855-6. Epub 2020 May 29. PMID: 32472494; PMCID: PMC7403249.