Culpable in the face of uncertainty? A perspective from military intelligence

Nada Khan is an Exeter-based GP and an NIHR Academic Clinical Lecturer in General Practice at the University of Exeter. She is also an Associate Editor at the BJGP.

When Eliza Manningham-Buller, the former Director-General of MI5, talks about decision-making, you listen. At the recent King’s Fund Annual Conference, she spoke about navigating uncertainty and the fine line between culpable and non-culpable mistakes, lessons that resonate far beyond just intelligence work. In her world, decisions are often made on incomplete information, yet someone still carries the responsibility when things go wrong.

It made me think of general practice, where we often need to make decisions in that space crowded with uncertainty, juggling incomplete patient histories and still pending lab results against an endless cascade of tasks and correspondence. And when subsequent outcomes go wrong, it is easy to feel the weight of blame, even when the factors at play were never fully within our control. Manningham-Buller’s distinction turns on a simple question: was the outcome the result of a failure of judgement, or simply of incomplete information and systemic factors? Being culpable means that someone deserves to be blamed or considered responsible when something bad happens. But how deserving is that blame in today’s general practice?

Decision making and diagnostic uncertainty

A typical day in general practice involves a series of judgement calls made without always being able to piece together the full picture. GPs are well versed in managing uncertainty, and given the undifferentiated nature of cases presenting to us, GPs experience some of the highest levels of holding that uncertainty compared to other specialties.¹

A recent review defines diagnostic uncertainty as a feeling of not knowing something, or ‘a subjective perception of an inability to provide an accurate explanation of the patient’s health problem’.² It is both cognitive and an emotional. Clinicians try to reduce that unsettled feeling by asking more questions, looking more closely at the patient notes, ordering more tests, safety-netting or using time as a diagnostic tool.³

How we react to uncertainty can shape outcomes. Sometimes we rely on the incomplete information in front of us and at other times, we fall back on familiar heuristics and prematurely close down the diagnostic process, a reaction I wrote about recently here in the BJGP.⁴

And this is where Manningham-Buller’s distinction matters. While diagnostic uncertainty is a natural and inevitable feature of working in general practice, diagnostic error is not, a distinction that is often conflated. When something goes wrong, the retrospective clarity of hindsight can make an adverse outcome appear predictable, even when it was not. This is the dangerous point where non-culpable uncertainty becomes incorrectly reframed as culpable error.

Burnout and the weight of uncertainty

Working with uncertainty has consequences. Data from the Oxford-Royal College of GPs Research Survey Service (RSC) shows that GPs who experience higher levels of diagnostic uncertainty are significantly more likely to report higher levels of emotional exhaustion and job dissatisfaction.⁵ These findings echo qualitative studies, where GPs describe the mental toll of working duty days, those high-volume sessions in which rapid decision-making is required while juggling fragmented histories delayed investigations, and electronic piles of unseen work.⁶ In a UK observational study, GPs tried to manage uncertainty in their regular clinics through safety-netting, delayed decisions, and monitoring rather than definitive diagnoses, falling back on that slower, Type 2 decision making that is not always available at first contact.^1,4But, the compressed nature of remote triage can pressurise decision-making, and mistakes don’t reflect carelessness, but instead the structural design of today’s general practice.

Interestingly, not all GPs experience uncertainty in the same way. Those more comfortable with uncertainty are also more likely to use shared decision-making, distributing uncertainty more openly with patients by naming it, working within it collaboratively and possibly reducing the private emotional strain.¹ GPs with a more psychosocial, rather than biomedical epistemology also experience less stress when facing diagnostic uncertainty.¹ Maybe the problem isn’t just uncertainty itself, but how we are expected to carry it where we work in the gaps between incomplete information and constrained time.

Where culpability fits in

Just as Eliza Manningham-Buller drew a clear distinction between mistakes arising from negligence and those arising from incomplete intelligence, general practice needs the same conceptual clarity. Many outcomes that appear retrospectively ‘avoidable’ are not avoidable in the moment. They are non-culpable and reflect the consequences of operating with insufficient data, under structural constraints, in a system that disperses crucial pieces of information across teams and workflows.

Why is it hard to tolerate diagnostic uncertainty? GPs fear committing medical errors and fear that uncertainty will be retrospectively reframed as a culpable failure. Many complaints centre on perceived diagnostic delay or quality of clinical care, often judged with the clarity that only hindsight provides.⁷ Patients might put in a complaint to ‘place responsibility’ or prevent mistakes from happening again, but this retrospective framing can make an uncertain decision appear culpable when the picture was genuinely uncertain and reflects the kind of ambiguity that is routine in general practice but invisible in hindsight. When uncertainty is judged retrospectively, structural problems risk being misinterpreted as personal error. 

How to help

Supportive structures can mitigate the emotional impact of uncertainty. Sometimes, having the chance to talk to trusted colleagues to reflect openly and safely about knowledge gaps or suggested plans can help.¹ Collaborative learning groups, case discussions, and environments where clinicians can reveal uncertainty without fear of judgement help redistribute cognitive load and reduce the risk of internalised blame.

We also need systems that acknowledge the reality of uncertainty, which include better continuity, clearer pathways, protected time for reflection, and complaints processes that distinguish between error and the inherent ambiguity of working in general practice. Naming uncertainty, normalising it, and embedding it in our structures is not an admission of weakness, but is an essential condition for safe, sustainable practice.

General practice means working in the grey zone every day, navigating the space between the clarity and uncertainty that defines first-contact care. Manningham-Buller’s distinction between culpable and non-culpable mistakes offers a language to describe that space more honestly. Much of what we carry as individual blame arises not from failures of judgement, but from the unavoidable ambiguity of general practice and the structural constraints around it. If we can recognise that difference, and create systems that support clinicians working in uncertainty, it may not only protect GP wellbeing, but also strengthen patient safety. Uncertainty will always be part of general practice, but it does not always have to be carried alone.

References

1. Alam R, Cheraghi-Sohi S, Panagioti M, Esmail A, Campbell S, Panagopoulou E. Managing diagnostic uncertainty in primary care: a systematic critical review. BMC Fam Pract. 2017;18(1):79.
2. Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and Measuring Diagnostic Uncertainty in Medicine: A Systematic Review. J Gen Intern Med. 2018;33(1):103-15.
3. Russell J, Boswell L, Ip A, Harris J, Singh H, Meyer AND, et al. How is diagnostic uncertainty communicated and managed in real world primary care settings? BMC Prim Care. 2024;25(1):296.
4. Khan NF. Fixation error: when thinking fast becomes a patient safety risk. Br J Gen Pract. 2025;75(758):412-3.
5. Zhou AYZ, S.S.; Hodkinson, A.; Hann, M.; Grigoroglou, C.; Ashcroft, D.M.; Esmail, A.; Chew-Graham, C.A.; Payne, R.; Little, P.; de Lusignan, S.; Cherachi-Sohi, S.; Spooner, S.; Zhou, A.K.; Kontopantelis, E.; Panagioti, M. Investigating the links between diagnostic uncertainty, emotional exhaustion, and turnover intention in General Practitioners working in the United Kingdom. Front Psychol. 2022;13.
6. Sinnott C, Moxey JM, Marjanovic S, Leach B, Hocking L, Ball S, et al. Identifying how GPs spend their time and the obstacles they face: a mixed-methods study. Br J Gen Pract. 2022;72(715):e148-e60.
7. O’Dowd E, Lydon S, Madden C, O’Connor P. A systematic review of patient complaints about general practice. Fam Pract. 2020;37(3):297-305.

Featured image by Sergiu Nista at Unsplash