2. What is the solution?

The SDM process traditionally has used patient decision aids to present risk, benefit, and alternatives with a goal of also eliciting, understanding, and incorporating a patient's values and preferences in the decision-making process. However, patient preferences and values are not stable or easy to assess, varying as a function of contextual factors [1]. Furthermore, even if the physician and patient come to a good understanding of the underlying risk-benefit ratio of various choices, there is no evidence that patients prefer less extensive testing and treatments [6]. Our role as physicians should go one step further, including navigating through the uncertainty of each choice. If we leave patients to make decisions on their own based on risk-benefit ratios alone, then we are failing not only to provide high quality care but also care that maximizes stewardship of resources.

In order to maximize stewardship of resources, SDM must include careful consideration of the degree to which uncertainty can be reduced and recognition of when the remaining uncertainty may be irreducible (Figure). The physician's role is to bring the patient from his or her original position of knowledge to the physician's position of knowledge, and then together they must understand the remaining level of uncertainty based on aligning available testing and therapy with a patient's preferences and values. This requires educating patients about what is known and what cannot be known, the irreducible uncertainty. If we remain complicit with patients in not addressing this uncertainty, we escalate both our own and our patients' anxieties, and we may instead seek additional diagnostic tests and therapies of marginal benefit. The burden of this anxiety is difficult for patients and their families to deal with, impeding their ability to live in the present and, subsequently, diminishing their quality of life [7].

3. What needs to happen next?

What skills does a physician need to manage the anxiety that comes with uncertainty? Ideally this task requires utilization of probabilistic thinking, communication skills, and self-reflection. Without clear understanding of probabilistic thinking or the skills necessary to communicate these complex ideas to the lay public, many physicians simply avoid the topic of uncertainty with their patients, or engage in futile attempts to obtain a mythical "complete" knowledge through further testing and therapies. Smith et al. suggest the following approach to managing uncertainty: (1) normalize uncertainty, (2) address anxiety and other emotions associated with uncertainty, and (3) manage the effect of the uncertainty on the patient's present quality of life [7]. Future study in SDM and overuse in healthcare should incorporate the concept of reducing anxiety around uncertainty on both the provider and patient side of the dyad.

4. Conclusions

It is undeniable that we are at a crossroads in the evolution of the American healthcare system with major changes afoot. As we move forward, it is essential that we tackle uncertainty and its impact on care and costs. In order to accomplish this, physicians must have training in understanding uncertainty and communicating uncertainty to patients.