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Managing Uncertainty. A core skill for GPs! Andrew Ashford. Areas of uncertainty. Significance / meaning of vague symptoms Diagnosis Problem definition What to do Examination Tests Referrals Interpreting results. Areas of uncertainty. What – and how much – to say Breaking bad news
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Managing Uncertainty A core skill for GPs! Andrew Ashford
Areas of uncertainty • Significance / meaning of vague symptoms • Diagnosis • Problem definition • What to do • Examination • Tests • Referrals • Interpreting results
Areas of uncertainty • What – and how much – to say • Breaking bad news • Discussing prognosis • End of life issues • How to start these discussions
Discussion prognosis in severe COPD • Questionnaire survey 389 GPs London • 72%: “...often necessary or essential” • 82% felt GPs had important role But... • Only 42% reported discussing prognosis • 50% “undecided” as to whether most patients with COPD wanted to know about prognosis • 64% found it hard to start these discussions ELKINGTON H et al (2001) GP’s views of discussions of prognosis in severe COPD Family Practice 18:4 pp 440-4
Strategies! • Group work!
Hewson et al 1996 • Tape analysis of consultations with four standardised patient cases • Headache, back pain, hypertension, abdominal pain • Nine strategies identified
1. Context, symptoms and signs • Defines the context of the diagnosis • Explains symptoms and signs as part of the expected spectrum of the disease
2. Alternative diagnoses • Eliminates alternative diagnoses by dealing with patient fears, • giving reasons in the context of the patient’s belief system
3. Gives prognosis • Describes prognosis in terms of • Likely course of the disease • Expectations of treatment
4. Key problems • Negotiates key problems or issues that are important to both patient and physician
5. Negotiates plan • Negotiates the plan, ensuring that the patient understands, and is willing and able to comply, given his/her particular context
6. Diagnoses provisional • Keeps diagnostic options open by making provisional diagnoses while keeping alternatives in mind
7. Considers “critical” diagnoses • Is circumspect and takes action to minimize the possibility of missing other critical diagoses
8. Using time • Plays for time by allowing signs and symptoms to develop to help clarify the diagnosis
9. Saftynetting • Plans for contingencies by providing appropriate “if ..., then ...” statements concerning situations requiring further action
“Strategic Medical Management” • ...based on tacit knowledge that is seldom explicitly articulated or taught • ...potential implications for enhancing instruction and assessment in medical education HEWSON MG et al (1996) Strategies for managing uncertainty and complexity Journal of General Internal Medicine 11:8 pp 481-5
Case Study 45 yr old lady, moderately unwell for 10 days, with persistent mild headache, transient rotatory vertigo and nausea on day 1, vague fluey aches for a few days, now better, just feels “not right” still, and concerned “something else going on”.
Past history Diagnosed with ME years ago, problems with fatigue, muscle aches, so currently not working Nil else significant
Examination BP normal CNs all normal Rhomberg, Unterbergers normal Tests higher cerebral function normal
Consultation skills • What works? • What doesn’t?
Useful phrases • “I don’t know what is causing your [symptoms], but I am clear there is NO evidence of anything serious going on today” • “In particular, there is no evidence of [patient fear]. • “If this was the case, I would have expected [specific symptoms and signs]”
Useful phrases • “Research has shown that the majority of these unexplained symptoms do go as mysteriously as they came, so it’s safe to wait and watch for a time” • “To be on the safe side I would like to see you again in [no of days/weeks], and if necessary repeat the examination” • “IF ...this happens, THEN I need to see you earlier / immediately”
Improving your management of uncertainty • See lots of patients! • Read the theory of medical decision making • Learn the natural history of common primary care diseases • Use incremental investigation strategies • Ask your colleagues • Saftynet intelligently • Get comfortable with saying “I don’t know … but you are safe!”
Finally…remember In solving problems, GPs have to:- • Tolerate uncertainty • Explore probability • Marginalise danger Whereas hospital specialists have to:- • Reduce uncertainty • Explore possibility • Marginalise error Marshall Marinker 1998
