STRATEGIES FOR MANAGING UNCERTAINTY AND COMPLEXITY

OBJECTIVES: To identify strategies involved in the diagnosis and treat ment plans of primary care problems that are uncertain and complex. ME THODS: In this exploratory study we observed primary care physicians e ncountering standardized patients who portrayed typical primary care p roblems involving uncertainty and complexity. First, we analyzed 10 ta pes of nine physicians with a range of clinical experience (first-year residents through faculty physicians) interacting with four standardi zed patient cases (headache, back pain, hypertension, and abdominal pa in). We analyzed the 10 tapes to determine the regular occurrence of p hysician behavior patterns that we later described as strategies. Then , using a written questionnaire, 19 general internal medicine faculty physicians from our hospital and from an affiliated hospital rated the perceived importance of these strategies for clinical practice in gen eral. Finally, we checked the incidence of the strategies: (1) across a range of six cases (headache, back pain, hypertension, abdominal pai n, fatigue, and well-adult care) using six first-year residents (a tot al of 19 encounters), and (2) across different levels of clinical expe rience using the standardized patient case of headache involving eight physicians (first-year residents through faculty physicians). RESULTS : Nine strategies were identified, and each was rated as important to primary care clinical practice. The strategies were: (1) defines the c ontext of the diagnosis and explains the signs and symptoms as part of the expected spectrum of the disease; (2) eliminates alternative diag noses by dealing with patient fears, giving reasons in the context of the patient's belief system; (3) describes the prognosis in terms of t he likely course of the disease and expectations of treatment; (4) neg otiates key problems or issues that are important to both patient and physician; (5) negotiates the plan and ensures patient understands, an d is willing and able to comply, given his/her particular context; (6) keeps diagnostic options open by making provisional diagnoses while k eeping alternatives in mind; (7) is circumspect and takes action to mi nimize the possibility of missing other critical diagnoses: (8) plays for time by allowing signs and symptoms to develop to help clarify the diagnosis; and (9) plans for contingencies by providing appropriate i f/then statements concerning situations requiring further action. The strategies were used in each of the six cases, and by physicians with all levels of clinical experience. CONCLUSIONS: The nine strategies le d to the generation of a construct we termed ''strategic medical manag ement,'' which refers to the management (diagnosis and proposed treatm ent) of uncertain and complex medical problems in primary care. The co nstruct provides a more elaborated framework in which to view clinical decision making and integrates recent ideas concerning doctor-patient communication into this process. Strategic medical management appears to be based on tacit knowledge that is seldom explicity articulated o r taught. It has potential implications for enhancing instruction and assessment in medical education.