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Under the topic of dealing with uncertainty, most people will immediately think of the difficult patient with the unknown diagnosis. That moment when “diagnosis deferred “ on the EMIS read coding is all you can think to put.
In fact, there are many areas where uncertainty affects our jobs –
- the consultation as a whole, from differential diagnosis right through to management and review;
- the patient and the way they interact with you;
- their uncertainty about what is wrong with them and how treatments may affect them;
- the ever-changing role of the GP and the constant changes in the service provision and financial - in a word, your future.
Maybe the title of General Practitioner is synonymous with uncertainty and we just didn’t realise it.
Why do we worry?
Doctors are expected to do the impossible – it is our job to retain large volumes of acquired knowledge, and in a very short space of time fit a list of presented complaints against this knowledge to come up with the diagnosis. We then have to navigate the mind field of the patient’s ideas and concerns to reach a mutually acceptable plan.
It is well documented that, especially in rare or more complicated conditions, doctors also rely on intuition and instinct. With ever increasing litigation and accountability, it is not surprising that doctors are concerned that making a decision on experience and instinct will not stand up to scrutiny and is not truly evidence based.
We often feel its our job to alleviate the patient of their worry – “My brother died of cancer last year, doctor, and I'm so worried that will happen to me too”. You do your bit – history, exam, maybe a few tests – the pt leaves reassured and you are left with the worry. How many times have we said it – “Everything is fine, please don’t go home and worry”, but short of reaching for your magic ball who knows how long everything will truly be fine?
What can we do?
It happens to us all, and it's experience and time which leads you to the knowledge that uncertainty is part of the job. You can't alleviate it, but you can learn to deal with and live with it.
The Consultation – we are all so well versed with consultation models that we sometimes forget the tools they offer. Think Neighbour with both safety-netting and house-keeping. These are key points to help deal with uncertainty. Whenever I see a child with a tummy ache which seems very benign I always say to the parents: "Things change, so just because I'm reassuring you now, if she starts to be sick etc call us back". It' important to hand back some responsibility to the patient so you don’t go home with that nagging feeling.
The Patient – be aware of their uncertainty about you and what you are offering. This can be very apparent when you are training – they couldn’t get in to see the senior partner so they have come to you under duress. If you recognise this and mention it often you can build a relationship on your own terms rather than a little extension from their usual doctor. If you manage this they are more likely to come back to you for follow-up and feel confident and compliant with your suggestions of treatment.
Other tools – some have suggested the use of software tools to combine hard data with more observational comments. This would take the uncertainty out of diagnosis but would it change our jobs in away we would find acceptable?
Discussion points - preparation for DRC groupwork
- Consider an encounter in practice which left you with the feelings of uncertainty, and how you dealt or are in the process of dealing with them. In training the neat answer is always to “discuss it with my trainer” but think outside this for a moment – how will you deal with it next year as a locum, assistant or partner?
- Ask one of the partners if they would be prepared to talk to you about a time when things went wrong and the concerns and uncertainty were actually well founded – it happens and we shouldn’t be ashamed of missing things, sometimes the smallest meshed safety net is not tight enough.
- What do you think about tools for diagnosis – do you use them in your practice? How does the internet, general press and NHS Direct impact on patient uncertainty and they way you deal with it?
- "The MMR is safe – immunise your little darling." Is there any doubt in your mind?
Written by: Jane Savage
Last update: 29 August 2007