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.

TEN SIGNS YOU’RE A GEN Y DOCTOR

I’m taking a guilty break from my GP exam study, so it’s a brief blog from me this time.  How do you recognise a Gen-Y doctor? Let me tell you, as I sip my fair-trade chai latte and touch-type on my MacBook Air:

1.  You’ve actually used the word ‘chillax’ in a consultation.

2.  You’d like to save the world – but only if you can do it part-time. How else will you manage your eco-solar-chookshed and your sustainable-organic-vegetable patch?

3.  You play Words With Friends, not Sudoku, while you’re anaesthetising patients.

4.  The administration staff are amazed you can plug in a LAN cable. Or fix the printer. Or touch-type. Or, heaven forbid, SEND A FAX YOURSELF!

5.  You’re planning a Locum Odyssey that entails surfing/working around the country for a few years. YOLO!  (Also, you know what YOLO means.)

6.  You’re not going to hang your diploma on your clinic wall. You’re going to hang photos you took on your DSLR of your hot-air-ballooning adventure over Myanmar, or your trek through the remote Nicaraguan jungle, or your windsurfing tour of the Maldives…

7.  You consult the Twittersphere, not the library, to find out about the most up-to-date medical research.

8.  You’re considering early retirement after 3 years of full-time employment.

9.  You’ve never seen a case of Smallpox. Or Polio. Or TB, Measles, Diptheria, Tetanus… or pretty much any vaccine-preventable disease. (Unless you live in Northern NSW, that is.)

10.  If the Internet shut down, you might not remember how to be a doctor.  See, you haven’t bought textbooks, because they go out of date before they hit the shelves these days. (Scary thought, that one…)

That’s all for now. Back to the books… Or should I say, back to my online subscriptions, FOAMed and RACGP website tutorials?

MODERN MEDICINE: A CENTURY OF PROGRESS? George Bernard Shaw’s 1906 ‘Dilemmas’ hold true

George Bernard Shaw was a very clever man, and he wasn’t too fond of doctors. The Irish playwright penned The Doctor’s Dilemma, a sometimes scathing, sometimes sympathetic reflection of Modern Medicine circa 1906. Having shamelessly stolen the off-copyright title for my blog, I thought I better pay tribute to his fascinating insights, and ask the question – have we made much progress in a century?

 While the play itself is certainly insightful, the preface is pure gold. I’ll share some of my favourite George-isms, though I’d highly recommend reading it, as a humbling exercise for the modern doctor. It’s a poignant reminder of the historical (and sometimes current) follies of our profession.  Let’s start with:

   “The demands of this poor public are not reasonable, but they are quite simple. It dreads disease and desires to be protected against it. But it is poor and wants to be protected cheaply….What the public wants, therefore, is a cheap magic charm to prevent, and a cheap pill or potion to cure, all disease. It forces all such charms on the doctors.”

 As a man of science, George lamented the lack of scientific rigor amongst medical men of the time. He thought doctors too often were caving to the public’s push for such magic charms.

   “They are not trained in the use of evidence, nor in biometrics, nor in the psychology of human credulity… Further more, they must believe, on the whole, what their patients believe… When the patient has a prejudice the doctor must either keep it in countenance or lose his patient.”

The dilemma of challenging your patient’s beliefs (at the risk of losing the therapeutic relationship) still applies – as any GP who has refused antibiotics for a snotty child will attest to. It’s also important to point out a common folly still committed today;

   “Doctors are just like other Englishmen: most of them have no honor and no conscience: what they commonly mistake for these is sentimentality and an intense dread of doing anything that everybody else does not do, or omitting to do anything that everybody else does.”

He was concerned that doctors of the time sometimes exchanged scruples for cash, particularly while working as sole traders whose livelihoods depended on their popularity. Remember, of course, that doctoring was a lowly-paid profession in 1906.

   “Private medical practice is governed not by science but by supply and demand; and however scientific a treatment may be, it cannot hold its place in the market if there is no demand for it; nor can the grossest quackery be kept off the market if there is a demand for it.”

George lived through the era of emerging germ theory, and watched it shape the profession. I think this statement holds more merit than any other he penned, particularly on the effect germ theory had on our modern paradigm of disease/cure – and the often-times overlooked art of healing.

   “We are left in the hands of the generations which, having heard of microbes much as St. Thomas Aquinas heard of angels, suddenly concluded that the whole art of healing could be summed up in the formula: Find the microbe and kill it. And even that they did not know how to do.”

Too true, George – and what would a scathing review of the medical profession be without some reflection on doctor’s egos, or self-righteousness? At times, it can feel we haven’t come that far in a century…

   “Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words “Remember that I too am mortal.”

    “The surgeon, though often more unscrupulous than the general practitioner, retains his self-respect more easily. The human conscience can subsist on very questionable food. No man who is occupied in doing a very difficult thing, and doing it very well, ever loses his self-respect.”

George did cut us a little slack though, towards the end. He honoured the selflessness of the medico in attending people in their hour of need, particularly the country GP.

    “When the baby is suffering from croup, or its mother has a temperature of 104 degrees…nobody thinks of the doctor except as a healer and saviour. He may be hungry, weary, sleepy, run down by several successive nights disturbed by that instrument of torture, the night bell; but who ever thinks of this in the face of sudden sickness or accident?”

    “Every general practitioner is supposed to be capable of the whole range of medical and surgical work at a moment’s notice; and the country doctor…often has to tackle without hesitation cases which no sane practitioner in a town would take in hand without assistance.”

I believe (and hope) we’ve made some progress since 1906. Particularly in evidence-based decision-making and professional transparency, to help remove the public’s doubt that our decisions might be based on a financial interest in our patient’s ill health! At times though, the culture of ‘find the microbe and kill it’, and ‘doing what everyone else does’ doesn’t appear to have changed much in a century. Something for us to work on, perhaps?

Thanks for your eternal wisdom Mr Shaw, and may it continue to give pause to many more generations of doctors ahead of us.