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Dealing with Uncertainty in General Practice

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Dealing with Uncertainty in General Practice Quality in Primary Care 2011;19:175–81 # 2011 Radcliffe Publishing Discussion paper Dealing with uncertainty in general practice: an essential skill for the general practitioner Margaret O’Riordan MD National Director of Specialist Training in General Practice, Irish College of General Practitioners, Dublin, Ireland Andre´ Dahinden MD General Practitioner, SGAM, La Neuveville, Switzerland Zekeriya Aktu¨rkMD Professor, Atatu¨ rk University Medical Faculty, Department of Family Medicine, Erzurum, Turkey Jose´ Miguel Bueno Ortiz MD International Officer, Spanish Society of Family Community, SEMFYC International Section, Barcelona, Spain Nezih Dag˘ deviren MD Professor, Trakya University Medical Faculty, Department of Family Medicine, Edirne, Turkey Glyn Elwyn MD Professor, Department of General Practice, Centre for Health Sciences Research, Cardiff University, Neuadd Meirionnydd, Wales, UK Adrian Micallef MD Quality Assurance Secretary, Malta College of Family Doctors, Malta Mikko Murtonen MD General Practitioner, Finnish Association for General Practice, City of Espoo, Espoon kaupunki, Finland Marianne Samuelson MD Professor, De´ partement de Me´ decine Ge´ ne´ rale, Faculte´ de Me´ decine, Universite´ de Caen, Caen, France Per Struk MD Consultant, Czech Society of General Practice, Praha, Czech Republic Danny Tayar MD Consultant, The Mifne Centre, Tel Aviv, Israel Janecke Thesen MD Senior Registrar Consultant/Researcher, The National Centre for Emergency Primary Health Care, University of Bergen, Bergen, Norway Background paper by Members of the European Association for Quality in General Practice/Family Medicine (EQuiP) 176 M O’Riordan, A Dahinden, Z Aktu¨ rk et al ABSTRACT Many patients attending general practice do not from the patient’s perspective is suggested. A good have an obvious diagnosis at presentation. Skills to doctor–patient relationship is vital, creating trust deal with uncertainty are particularly important in and mutual respect, developed over time with good general practice as undifferentiated and unorgan- communication skills. Evidence-based medicine ised problems are a common challenge for general should be used, including discussion of prob- practitioners (GPs). This paper describes the man- abilities where available. Trainers need to be aware agement of uncertainty as an essential skill which of their own use of heuristics as they act as role should be included in educational programmes for models for trainees. Expression of feelings by both trainee and established GPs. trainees should be encouraged and acknowledged Philosophers, psychologists and sociologists use by trainers as a useful tool in dealing with uncer- different approaches to the conceptualisation of tainty. Skills to deal with uncertainty should be managing uncertainty. The literature on dealing regarded as quality improvement tools and in- with uncertainty focuses largely on identifying rele- cluded in educational programmes involving both vant evidence and decision making. Existing models trainee and established GPs. of the consultation should be improved in order to understand consultations involving uncertainty. An alternative approach focusing on shared deci- Keywords: general practitioners, training, uncer- sion making and understanding the consultation tainty Introduction The conceptual approach to managing uncertainty Uncertainty and unpredictability are core elements in the complex system of healthcare provision, present- It is possible to adopt a number of different ing challenges for health professionals, patients and 1 approaches which influence the way in which we managers. Skills to deal with uncertainty are particu- conceptualise the importance and the implications larly important in general practice as undifferentiated of managing uncertainty. Taking a philosophical ap- and unorganised problems are a common challenge proach, the existentialist believes that most of the time for general practitioners (GPs),2 in contrast to the 3 humans manage to bridge the gap between the need caseload of many hospital colleagues. Since there is for order and constancy on one hand and the un- usually no obvious diagnosis at point of patient avoidable reality of lonely and limited existence in a presentation, one can say that uncertainty is inherent chaotic and therefore unpredictable world on the other. in general practice. Therefore uncertainty arises when a patient presen- Doctors’ and patients’ level of certainty seem to be tation produces a sense of helplessness in the doctor directly correlated and interdependent. Validated scales (a product of lifelong existential reality). have been developed to measure uncertainty in phys- 4 5 If we were to adopt a psychological approach we icians and as a source of stress for patients. Tolerance could say that uncertainty can arise due to a cognitive of diagnostic uncertainty seems to affect test ordering 6 process (difficulty in perception and interpretation of behaviour, and medico-legal worries have been im- facts by the doctor), and/or a personality clash and/or plicated as one of the reasons for the increasing use of 7,8 as an indivisible part of doctor–patient interaction and tests by GPs. On the other side, uncertainty is a communication. In contrast, the sociological literature powerful source of stress for patients9 and GPs10 and 11 challenges the assumption that human beings are has been linked to burnout. Grol et al linked uncer- rational decision makers and instead describes the tainty to personality and developed a scale of risk 12 so-called ‘social processes model’ of decision mak- avoidance. ing.13 This paper describes management of uncertainty as Rational thinking is an important part of the process an essential skill, which should be included in edu- but is not the whole story. Rather than balancing the cational programmes for both trainee and established pros and cons of any decision in an objective and GPs. It was developed as a result of several discussion logical way, the social processes model emphasises the group meetings of interested EQuiP delegates, general wider context within which decisions are made, risk is reading around the subject and a focus group held at a managed and uncertainty is dealt with. Decision making European conference. is seen as a complex, iterative social process, Dealing with uncertainty in general practice: an essential skill for the general practitioner 177 influenced by personal experiences and by the views of Medical decision making and advice from other people (the validity of which is based on the level of trust between the giver and the Science appears to offer a sense of security in medical receiver of the information). Objective information decision making but this may be lost when faced with and rationality therefore play only one, sometimes uncertainty. Analysing decision making is cited as a key area in helping doctors to deal with uncertainty, small, part in a ‘knowledge construction’ process that 19–24 underlies how people deal with uncertainty as they and this view is supported by the literature. make clinical decisions.14 Patient-related factors such as co-morbid con- ditions, quality of life indices, the financial situation and restricted access to health care are all important factors in medical decision making.23 Summerton3 A practical approach to suggests that decision making in primary care is a very different process from that undertaken by hospital- uncertainty based doctors. It is particularly important to analyse symptoms from a patient’s perspective, taking context There are many consultations where there are no into account. Experienced clinicians seem to base their straight answers, no clear diagnosis and no obvious diagnoses on cognitive structures which they have treatment, where guidelines and decision-making pro- developed from dealing with a series of similar patients tocols do not lead to a satisfactory outcome. In this in the past. Having reflected on how they dealt with situation, at one extreme the doctor who believes in one patient they then extrapolate their findings to their own infallibility when faced with diagnostic others. This involves a combination of reflection in decisions can be a source of danger, as can the doctor action (during the consultation) and reflection on 25 at the other extreme who struggles with indecision on action (afterwards). 26 a daily basis. For the majority, however, uncertainty is Arborelius et al analysed consultations where GPs a normal component of the working day and dealing appeared unsure in their interactions with patients – with it is a necessary skill. The literature on dealing this appears to have been compounded by the fact that with uncertainty in practice focuses largely on iden- the GPs did not acknowledge and use their feelings of 20 tifying relevant evidence and decision making. uncertainty as useful information. Baerheim describes the diagnostic process starting from a patient’s history and proceeding to a result that can be categorised. Identifying relevant evidence Patients do not present their symptoms as a list but In order to identify evidence, one should know that rather in the context of a story of how these symptoms thereisappropriateevidencepresent.Then,oneshould have affected their lives and the chronological order in have access to the evidence at the time it is needed which they appeared – a story of illness. during the consultation. Evidence-based medicine is a The doctor gathers, sifts and prioritises the infor- useful tool when faced with uncertainty, particularly
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