“A key element in developing wisdom from knowledge is learning to tolerate ambiguity and uncertainty.”  — Danielle Ofri, MD

BACKGROUND

In every facet of healthcare, we are faced with uncertainty.  Despite various strategies to reduce uncertainty, such as the use of evidence-based guidelines and clinical decision tools or algorithms, we are often still unable to know with certainty whether we have arrived at the correct diagnosis, have designed the optimal treatment plan, and/or have accurately predicted a patient’s prognosis. Some have described this as “the fog of healthcare”, a reference to the well-known “fog of war”.  This lack of certainty can be both frustrating and disquieting, especially when we are faced with the responsibility of making decisions that could have a major impact on the health of our patients and their families.

In these uncertain situations, our reactions can not only impact our own cognitive processes, but can, through verbal and non-verbal communication, impact our patients  – at times evoking their anxiety and undermining the confidence they have in their healthcare. At the same time, uncertainty has its benefits – it can lead us to a closer examination of the information we have available, to a deeper contemplation of the situation at hand, and to more effectively joining with our patients in a partnership to find the best way forward.

Uncertainty, perhaps like death and taxes (and e-mail!), is also a fact of life.  Perhaps no year in recent history has made that point as clear as the one we’ve spent living through a deadly pandemic. We’ve all felt a great sense of “unknown”, not only in healthcare, but also in our daily lives and with our future.  Schedules, trainings, job interviews, conferences, career moves, weddings, funerals, vacations and many other things were cancelled or put on hold — and it’s remained quite uncertain when or if we ever might get back to “normal”, whatever that is…

This session offers you the opportunity to reflect on your own experiences with uncertainty during the clerkship year, both patient-related and personal, and to consider how the arts & humanities may help us confront and gain comfort with uncertainty.  Before the session you’ll complete a reflection assignment that is detailed below.  Then, on Monday, 1 March we will meet for a plenary session and small group discussions.  In the plenary session we will listen to a narrative of a provider who has led a palliative care team during the height of the COVID pandemic.  We ask you to identify themes of uncertainty in the narrative.  What reactions do you have while listening?  Why might you be having those reactions? What might be some implications of those reactions on a patient you may care for in the future?  And what are the implications on your own well-being?  Immediately after the plenary we’ll break into virtual small groups for discussion.  Those discussions will allow you to reflect as a group on the speaker’s narrative and to share your individual reflections on uncertainty.

PREPARATION for the panel & small group session:

1. REQUIRED READING from sources above:  “Medical Humanities: the Rx for Uncertainty?” (D. Ofri) and “Adverbs” (K.B. Shah).   You may read or watch other resources as you have time.
2. Prepare a reflective art or written assignment, as detailed below.  (DUE in Sakai NLT Friday, 26 FEB @0800)
3. Before Monday’s large group session, READ this article, written by our plenary speaker, Dr. Leiter.  Join the Zoom link NLT 1145 on Monday, 1 March. Small group discussion will follow on Google hangouts (see WSIB in Sakai).

GUEST SPEAKER:  Dr. Richard E. Leiter is a palliative care physician at the Dana-Farber Cancer Institute and Brigham and Women’s Hospital, and an Instructor in Medicine at Harvard Medical School. He received his medical degree and a masters in Medical Humanities and Bioethics from the Northwestern University Feinberg School of Medicine and completed his residency and chief residency in Internal Medicine at New York-Presbyterian Hospital/Weill Cornell Medical Center. He then completed a clinical hospice and palliative medicine fellowship at the Harvard  Interprofessional Palliative Care Fellowship Program and a research fellowship in the Department of Psychosocial Oncology and Palliative Care at Dana-Farber. His work has appeared in the New England Journal of Medicine, The New York Times, and STAT.

ASSIGNMENT – Reflection through Art or Writing:

You have 2 options for this assignment; both options will utilize the framework below to guide your reflection:  

1) Create a work of art (and write accompanying 1-2 paragraph explanation) that reflects on uncertainty.  This can be a painting, sketch, photograph, sculpture, poem or prose, short-story, music performance, interpretive dance, etc (you can be creative with the modality — that’s the point!).  The 1-2 paragraph explanation should give some background on why you chose that modality and describe how it helps you reflect on uncertainty and how this might help you face uncertainty in future patient care situations.

…OR…

2) Write an R.S.I.R. paper (minimum 2 pages) similar to what you’ve written in past Reflective Practice sessions.  (see framework below)

FRAMEWORK FOR REFLECTION

Set the Stage:  Recall a patient situation during your core clerkship in which uncertainty was a prominent theme or posed a barrier to medical decision making.  Perhaps there was uncertainty about the diagnosis or treatment plan or other aspect of care.  Briefly set the stage with a few sentences about the situation.

Reaction:  As stimulated by this patient care experience with uncertainty, and after reading the required supplemental resources, identify at least 2-3 reactions you had to this encounter and/or to the readings.  Consider the following:

• Your thoughts and feelings about having to make a diagnosis and develop a treatment plan in a situation in which the correct diagnosis (and thereby the optimal treatment plan) is uncertain.
• Your reactions to the supplemental resources as they relate to uncertainty — what struck you as particularly poignant?

*Note: When writing this section, list your affective reaction followed by 1-2 lines describing what evoked your reaction.

Sources/Your Story:  Through the medium of your personal narrative, explore the sources of these thoughts, feelings, and reactions. Your narrative must include specifics and be written in the first person. Your sources should include an exploration of the following:

• What are your experiences dealing with uncertain situations in the past (this can be the recent past during the pandemic…or more distant past, or both)?
• How was uncertainty dealt with and discussed in your family/home of origin?
• How was uncertainty dealt with and discussed in the community, culture, religious group, etc. in which you were raised?
• How do you perceive uncertainty to be viewed in the military community, medical community, and your current family/community?

Implications:

Analyze the potential implications of your reactions to uncertainty in healthcare.  Think about your clerkship year and times you felt that the path ahead for a patient (diagnosis, patient desires, treatment, prognosis, family desires) was uncertain. At a minimum, consider the following questions:

• What challenges does coping with uncertainty pose for you as a healthcare professional?
• What do you think you will do in such a situation and what are the impacts of those anticipated actions? Be sure to include both the positive and negative implications for each of your reactions.

Review:

What have you learned about yourself as a result of writing this reflection on uncertainty?  What are some realistic steps you might take when you face uncertain situations as a healthcare provider?  What questions might you have for your peers that would help you find ways to confront and even embrace uncertainty?

Note: The reality of healthcare is that there are many situations in which there are no certain answers – for anyone. Your task is to consider how you will cope with these situations.  Simply planning to “learn more” or “read more,” while potentially helpful, avoids the challenge of reflecting on how you will cope with uncertainty when it is unavoidable. 

Note #1: Submit your paper in Sakai as a Word document.  If you created a work of art, take a picture of it and upload the picture AND the written reflection in Sakai (as PDF or other format).
Note #2: Include your last name in the file name.
Note #3: Include your email address in the header of your paper.

OBJECTIVES

By the end of the plenary and small group session on “Uncertainty”, students will demonstrate the ability to:

1.  Identify a patient situation during their core clerkships for which uncertainty was a prominent theme or barrier to medical decision making.
2.  Examine the impact of uncertainty on healthcare providers and medical teams AND on the care of the patient
3.  Examine how uncertainty has played a role in their own personal lives this year as a result of the pandemic.
4.  Reflect on the cognitive and/or affective insights gained from facing uncertainty both in the medical realm and in one’s personal life.
5.  Consider how these personal & work-related experiences with uncertainty may influence the approach to uncertainty in future patient care.
6.  Consider how the arts & humanities can enhance one’s acceptance and even appreciation for the uncertainty that is inherent in medicine.