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May 2021

Learning to tolerate clinical uncertainty in the face of covid-19

By Emily Parker.

In a recent discussion with a senior doctor, I was told, ‘a doctor who isn’t taking risks is not doing their job.’ As a PhD student, rationalising my research into uncertainty management in the emergency department (ED) is a skill I am still learning, yet this doctor had done it for me in one sentence. When initially presented with this quote, it is understandable that people may be wary of doctors taking risks. However, risk and uncertainty are often irreducible in the ED. Patients present to EDs with severe illness, often unable to give a medical history and doctors have limited time to reach a decision1. Therefore, being able to manage risk and tolerate uncertainty is a vital skill for doctors.

When deciding to admit or discharge a patient, ED doctors make a probability assessment by considering the benefits and risks of both options. A lot of the time, what is central to this decision is whether the patient is safe, or unsafe, for discharge2. What is considered a safe discharge can vary between doctors. For example, some doctors might admit a patient to avoid their symptoms getting worse whilst some would discharge the same patient and ask them to return, if and when symptoms get worse.

Research suggests doctors with less experience are more inclined to test and admit patients than senior doctors3. A lower threshold for ‘safe discharge’ suggests a lower tolerance for the uncertainty associated with sending a patient home. We have all experienced a lot of uncertainty this year and can relate to the anxiety it brings. But these anxious feelings and thoughts of doubt don’t seem to follow admission decisions. Hospitals are perceived as a place of safety, allowing access to a specialist opinion and deferring the decision to discharge away from ED. Where decisions are uncertain, junior doctors often admit to avoid the negative feelings associated with an uncertain discharge.

That is, until 2020 when covid-19 added a new dimension to decision making in the ED. I was lucky enough to interview junior doctors and registrars working in the ED throughout the first and second wave of the pandemic. The interviews focused on factors which influence uncertain admission and discharge decisions which inevitably included covid-19. Covid-19 had huge impact on the experience of doctors in training.

Junior doctors spent eight months on one particular specialty rotation, as oppose to four, increasing exposure and confidence in that particular field but reducing it elsewhere. Structured teaching time, away from the ward, was limited. A lack of visitors meant the assistance of family members and carers in establishing a medical history was not possible and cancellations of elective surgery meant patients who would have once been admitted, were repeatedly discharged by ED doctors. In an already high-stakes environment, covid-19 created even more uncertainty, left to the doctors to tolerate.

What my interview study revealed was that despite hospitalisation always carrying substantial risk of infection, the coronavirus pandemic meant that conversations about the risks of being in hospital started taking place more frequently and admission to hospital was avoided wherever possible. This is an approach to decisions which Professor Steve Goodacre called for in 20063, suggesting discharge from the ED should be the default position and only where evidence points to the benefits of admission, should admission to hospital take place. The junior doctors I interviewed stressed the importance of this throughout the pandemic, particularly for elderly, vulnerable patients who are frequently admitted for social reasons alone. Despite only two months as an ED doctor, the decision making approach of junior staff aligned with that of Professor Steve Goodacre.

It has been an unprecedented year for the health service but if there is anything we can take away from this, it is that where admission to hospital is not clinically necessary, it shouldn’t need to occur. Exposing patients, particularly elderly patients, to the risks of being in hospital should be avoided long after the pandemic. Hospital acquired pneumonias, loss of independence and confusion are all very real risks of being in hospital. These often occur because the patient has no support network at home or there are no safe options to get the patient home at night time, resulting in a discharge process too uncertain for the doctor to tolerate.

Pushing for discharge where clinically appropriate should remain in place but this can only happen if the systems in place within the community and social care allow a patient to be discharged home in a moral and safe way. The structures and knowledge on which an ED doctor can call on, allowing them to tolerate a discharge decision must be strengthened.

My wider PhD project is focused on enhancing uncertainty tolerance amongst ED doctors and if you would like to follow the project, follow @emilyeparker22.

1. Platts-Mills TF, Nagurney JM, Melnick ER. Tolerance of uncertainty and the practice of emergency medicine. Annals of emergency medicine. 2020 Jun;75(6):715.
2. Goodacre S. Safe discharge: an irrational, unhelpful and unachievable concept. Emergency medicine journal. 2006 Oct 1;23(10):753-5.
3. Lawton R, Robinson O, Harrison R, Mason S, Conner M, Wilson B. Are more experienced clinicians better able to tolerate uncertainty and manage risks? A vignette study of doctors in three NHS emergency departments in England. BMJ quality & safety. 2019 May 1;28(5):382-8.