THE ART OF UNCERTAINTY IN GENERAL PRACTICE

I’ve long felt that the art of General Practice is being comfortable with a moderate degree of uncertainty.  In my first term in General Practice, I frequently called my supervisor for advice, because I just couldn’t diagnose the patient based on the available information.  The advice was usually, “Hmmm… get her back in a few days. It will declare itself one way or another.”  This was difficult at first, and I’d fret about the patient leaving without a diagnosis.  But it worked a treat!  When they’d return, the issue had either resolved, or progressed to some recognisable clinical entity, and I could work them up appropriately.

In medical school, we learn the art of textbook diagnosis.  A patient has a collection of symptoms and signs that neatly correspond to a diagnosis, and we rote-learn the appropriate treatment to offer.  It’s easy to memorise, because A symptom + B sign = C diagnosis and we treat it with D cure.  If your only experience of health and disease is from a book, this is the way you expect medicine to work.

In our junior doctor years in the hospital, we learn the art of clinical diagnosis.  It rapidly becomes clear that in the real world, patients don’t fit into neat diagnostic boxes.  Instead, within our various specialty terms, we learn to fit cases into algorithms, and process them along a diagnostic pathway.  For example, a patient who presents with any form of chest pain will fall into the ‘chest pain algorithm’ and promptly be given aspirin, an ECG, a chest X-ray and blood tests, all before we have decided if they truly have cardiac chest pain.

The benefit of this approach is the ‘safety-net’ to capture mild atypical presentations of serious disease.  It also provides rapid case turnover in a busy public hospital.  The downside is over-investigation, over-treatment and the risk of wearing blinkers to alternative diagnoses.  For example, once a child with a wheeze is on the ‘asthma algorithm’, it’s easy to miss that the reason they aren’t responding to escalating asthma medication is because they actually inhaled a small plastic toy.

Once we enter General Practice, the diagnostic situation becomes even murkier.  We see things first in General Practice, before they evolve into symptoms worthy of the clinical algorithms we are so comfortable with.  We see conditions at the start of their clinical course – like early appendicitis, when it just looks like a central tummy ache.  We see pneumonia, when it’s a new chesty cough.  We see bowel cancer, when it begins as vague tiredness and constipation.  We see things evolve, and this ‘window’ of early disease is often not experienced by other specialties.  For new GP Registrars, this can be the hardest transition to make from hospital medicine to General Practice.

I’d hope that our specialist colleagues respect the vital role GPs play in sorting out these early presentations.  I’m quite sure the Surgeons don’t want to see every tummy pain in case it might turn out to be appendicitis – that would be an enormous waste of resources.  I’m also quite sure that a Surgeon wouldn’t necessarily be as skilled in managing the problem of early tummy pain – simply because they’d have their specialty blinkers on.  Would they give full consideration to the multitude of gastrointestinal, urological, gynaecological, endocrine, neurological, vascular and psychological causes of a bit of tummy pain, like a GP must?  Would they be comfortable not doing a diagnostic CT Abdomen, and simply asking the patient to return the following day?  The skill in General Practice is not just identifying who might have a serious specialty problem, or need an operation – it’s also diagnosing simple but bothersome things, identifying safe things, avoiding unnecessary tests, rationing public and patient dollars, reassuring worried well and educating patients on normal bodily symptoms.

Of course, if we make a diagnosis of something that needs further specialty input, we initiate the relevant investigation and treatment algorithm.  It’s always nice to ship off our patients to the specialist in neat diagnostic bundles, like ‘acute PR bleeding’ or ‘likely pneumonia’, with some relevant tests completed and a succinct summary letter.  It’s far less satisfying when intuition is telling you something serious might be evolving in this patient, but you can’t quite fit them into a diagnostic box yet.  All of us in General Practice have made those unsatisfying referrals of ‘vague neurological symptoms’ or ‘sub-acute abdominal symptoms’ and winced thinking of our specialty colleagues criticising our clinical prowess on the receiving end:

Summary Letter: “This patient is complaining of these vague symptoms late this afternoon, and I have no idea what’s going on but my gut is telling me something’s wrong, and to be on the safe side I’d appreciate it if you’d work them over up there will all your fancy gadgets and rapid access to bloods and imaging because I don’t feel safe about them going home tonight.”

Specialty Registrar: “Bloody GP. No idea what they’re doing. This patient doesn’t need to be in hospital”After the appropriate hospital workup has come back negative, and you’ve had a chance to observe them for 6 hours, of course.

I was recently amused to hear from an ex-Emergency Registrar, who had just begun in General Practice.  She hated having to send in these ‘crap referrals’ lest the ED staff criticise and judge her – as she knew they might, having worked there.  She was finally seeing it from the clinical reality of the referring GP’s side.  It’s all too easy to criticise the handling of incoming patients when you’re holding the position of knowledge and expertise, especially when these patients are sent to you for your expertise.  Of course they’re not exactly worked up as you’d like them to be, that’s why we’re sending them to you!

I greatly appreciate my specialist colleagues, and happily call on their wisdom and clinical expertise when I have a complex case, a seriously unwell patient or a patient with a specialist problem.  However, I do come across the common scenario of ‘if all you have is a hammer, all you see are nails’ when it comes to specialists looking at problems outside their field.  I sometimes think how hard it must be, both for patients and doctors, in countries where a GP isn’t involved in diagnosis and patients self-refer directly to specialists.  A patient with vague pelvic symptoms could be shipped between half-a-dozen different specialties, rack up huge bills, and probably have a lot of unnecessary investigations in the process.

I also wonder if our culture-based desire for a ‘diagnosis’ when unwell is contributing to the huge upsurge in patients seeking out alternative health providers.  Far too often, I have a patient tell me they have been ‘diagnosed’ with all sorts of odd conditions, that either don’t actually exist, or aren’t there when I test them.  Patients like to have a ‘diagnosis’ for their peace of mind.  If a shonky alternative healer tells you assertively that “You have X condition. This expensive cure I sell will definitely fix it”, you’ll feel satisfied and hopeful – even if it’s complete nonsense.  If your GP tells you, “I can’t give you a specific diagnosis, but I’ve ruled out all the serious or fixable things, and there’s been no scientific evidence that any treatments will help your symptoms, they’re all just a waste of money”, you’re likely to leave the doctor’s office feeling completely unsatisfied, and not healed at all.

I’m not advocating a shift towards over-diagnosing or over-investigating patients just to given them a label and make them happy.  We’d be taking advantage of vulnerable people if we did so, because we know better and we aim to offer healing based on science and ethics.  However, we must keep in mind that while professionally this skill may be lauded, our patients may not always appreciate uncertainty, and may look elsewhere for someone, anyone, who will tell them that something’s definitely wrong with them.  All the more reason to celebrate those skilled General Practitioners who acknowledge this need, who seek out and address patients’ fears and educate at every appointment. Uncertainty is certainly an art in General Practice.

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16 thoughts on “THE ART OF UNCERTAINTY IN GENERAL PRACTICE

  1. Pingback: General Practice is Messy | Genevieve's anthology

  2. Pingback: THE ART OF UNCERTAINTY IN GENERAL PRACTICE | FOAM4GP

  3. Very good! We are gatekeepers. I have been on the other end and know there is a great delusion clouding the eyes of SOME specialist colleagues of what GP’s actually do.

    We are a specialty of the uncertain, ambiguous and undifferentiated and chronic disease specialists.

  4. Time is not just the great healer but the great diagnostician. The Art of Masterly Inactivity is incredibly important in avoiding overmedicalisation and overtreatment as a knee jerk reaction,

  5. Embrace the uncertainty!

    The more medicine I do, the less certain I am. And therein lies the skill of the primary care specialist – dealing with ambiguity, understanding the protean manifestations of disease that don’t follow the textbook – such experience was traditionally born by making mistakes as trainees.

    I’ve been the ED reg, seeing a subset of primary care patients in the ED – easy to criticise as we saw only a tiny percentage of those filtered by primary care,…and yet juniors often forget that discharge back to the community is only possible after appropriate Ix and opinions not available in 15 mins of primary care. Ditto I have been the ICU reg, dealing with the septic patient on inotropes and ventilated, critical of the previous care in ED and primary care – forgetting that we only see others ‘mistakes’ and that the fulminant sepsis in front of us was only a vague back pain or lethargy a few days prior. A chance comment about a ‘missed diagnosis by the GP’ or ‘ED should have treated this sooner’ by staff on ICU can have devastating consequences – loss of trust in ‘their GP’.

    Verily it’s easy to crticise with the benefit of a retrospectoscope. Experienced clinicians ‘get this’. Again, as time goes on I am less afraid to say “I don;t know what’s going on here” and either practice watchful waiting or, if stakes high or ‘spidey sense’ on alert to refer early and explain m concerns. Having good relationships with colleagues in the tertiary centre helps.

    “How do you avoid mistakes? by experience? How to get experience? by making mistakes!” FOAMed changes that as we can tap into the collective wisdom of colleagues, sharing ‘corridor conversations’

    So, my tuppence worth :

    – embrace uncertainty, this is the discipline of primary care

    – engage the patient as active partner in the process, safety net

    – avoid the scattergun approach of investigations. Most things in primary care will declare themselves with a “tincture of time”. The skill is history, exam and appropriate Ix in a timely and appropriate fashion.

    – trust that little voice on your shoulder. It’s telling you something.

    • All very good advice. I totally agree with ‘a tincture of time’ – it’s a treatment I’ve only realised existed since entering GP-land. And it’s all about the safety-netting.

      Yes – the further along I go in this job, the less critical I aim to be of my colleagues where possible. Nothing tells a junior hospital doctor apart from an experienced one like the bitching about other clinicians, especially when they’ve never worked in that department!

      • There is only one answer that I know to uncertainty that lets you act, making life and death decisions rather than hesitating, and lets you sleep at night. It is certainty in yourself. It is centred around ethics, a deep knowing that you are doing the very best possible in an exceptionally complex human world of health and often conflicting evidence.
        Superficially this comes from not only selflessness in the face of the particular patient but also doing everything possible to acquire information. The psychological issue is having a selfless subconscious mind that can be innately trusted never to colour judgement with emotion or vested interest.
        The objective decisions come first. Then have the emotion for the patients after the decisions are made. It is the only way to know that the decisions are in the patient’s best interest rather than for the sake of popularity.
        That is when the doctor can honestly say to themselves that they are doing their best and have done their best for every patient. When a risk benefit decision gets an unlucky role, you know that you have done your best and could have done no more.
        And it shows. Patients sense it. It comes out in nonverbal communication and follows the selfless doctor like an aura. Deep selflessness is their halo that immediate engages the patient’s trust.

        This is the central issue of the doctor of heart and soul. Without it, you fall back on the protocols and false certainty of technology or worse still, doing what is populart rather than what is right.

  6. Pingback: THE ART OF UNCERTAINTY IN GENERAL PRACTICE | Dr Thinus' musings

  7. Great post , I will show this to my registrars when they start in GP land although I do think there is a small subset of patients who want you to NOT know what is wrong with them but you can reassure them its ‘not serious’. Does anyone else think this ?

    • I agree with Mark here. A good piece posing the same communicative dilemmas we ask as physiotherapists too. Knowing what is wrong is very different from knowing what is not wrong. Working from a paradigm of contemplative ignorance, I believe, helps us to keep an open mind about the Unknown.

  8. Pingback: Amazing Australian GP Bloggers, 2014 | Doctor's bag

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