We deal with uncertainty every day in general practice.
This month, we review 5 cases illustrating various reasons or things that may be contributing to uncertainty in general practice.
This is part 2 of a 3 part series, where we listen in on a webinar with Marlene Pearce, a GP based on the Sunshine Coast, QLD. In Part 1 of ‘Uncertainty in General Practice’, Marlene spoke about using clinical reasoning to assist, what to do when we’re stuck, as well as what pitfalls to avoid. In this episode, we consider what actually contributes to the uncertainty we experience.
View the recording to find out more:
Dealing with uncertainty is complex. If you consider the challenge of early, undifferentiated presentations, the relative likelihood of serious illness, the limits of location, consultation time, or the inherent limits of decision making tools, you will have a deeper appreciation of what you’re actually dealing with. Doing nothing, asking for help from colleagues, referring for advise and review, and allowing time to pass can all be very reasonable options, depending on the situation.
Being comfortable in uncertainty and managing patient expectations are skills – skills that can be honed over time.
Watch out for Part 3, where we look at minimising risk and maximising coping skills when dealing with uncertainty.
Why is there so much uncertainty in GP- because dealing with uncertainty is our job. No other discipline accepts it as much as we do. You will often hear the response “Oh that is not my area”. It is one of the things that drew me to my life’s work.
When uncertainty is due to the patient presenting early in the disease process, USE time as a diagnostic process. Review in person or by phone in half an hour, half a day, half a week. Use the gathering of blood tests & the time that takes to help elucidate the diagnosis. The best test is the passage of time.
That a serious illness is uncommon is of little interest to the person who has it. GP is based on pattern recognition, we keep in mind 3 patterns- how the patient usually responds to any illness, how most people respond to the conditions you are including in a differential diagnosis & how the patient is actin NOW. When there is a mismatch , call for assistance. I have seen all sorts -porphyria, extra abdominal hydatid cysts, hypokalemic periodic paralysis , familial mediterranean fever, acute pericardial effusion, HOCM, temporal lobe epilepsy, QT syndrome, gallstones in 8 year olds all found because the presentation did not fit the pattern of other diseases
Fortunately a diagnostic & management algorithm for abdo pain esp irritable bowel is soon to be available.
Guidelines are merely guides, they are useful servants & poor masters, they are very limited. In fact there are none available for a person with 3 or more chronic illnesses.
With children there are 2 critical questions-is the child sick & do you trust the parents/ guardians? If the parent esp the mother is reliable ask them if the child is sick
Share difficult decisions with patient, colleagues & ED or specialists. Your communication with them is of critical importance- phone call & a good letter explaining WHY you wants the patient observed or assessed.
Finally, the witching hour in GP is not midnight it is 6 pm on a Friday. That is when you roster your A teams & that is when you are extra careful