The Art of Uncertainty in Medicine

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I've long felt that the art of general practice is being comfortable with uncertainty. In my first training 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 recognizable 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 memorize, 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 always 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: 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.

When 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 stomach 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. This can be the hardest transition to make from hospital-based training 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 stomach 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 stomach 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 early stomach pain, like a GP must? Would they be as comfortable not doing a diagnostic CT Abdomen, and simply asking the patient to return in a day or two?

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, we might make a diagnosis of something that needs further specialty input. It's always nice to ship off our patients to the specialist in neat diagnostic bundles, like "acute gastrointestinal bleeding" or "likely pneumonia," with relevant tests completed and a tidy 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 criticizing our clinical prowess on the receiving end:

GP Letter: "This patient is complaining of these vague symptoms, and I have no idea what's going on but my gut is telling me something's wrong, and I'd appreciate it if you'd work them over with 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 six hours, of course.

I was recently amused to hear from an emergency doctor, who had just begun working as a GP. She hated having to send in these "vague referrals' lest the ED staff criticize and judge her -- as she knew they might, having worked there. She was finally seeing the clinical reality of general practice. It's all too easy to criticize 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.

I greatly appreciate my specialist colleagues, and happily call on their expertise when I have a complex case or a seriously unwell patient. However, I do come across the 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 of expertise. It must be tricky sometimes, for patients and doctors, in countries where a GP isn't involved and patients self-refer to specialists. A female patient with vague pelvic symptoms might find herself visiting half a dozen specialties, racking up huge bills, and having unnecessary invasive investigations in the process.

I also wonder if our Western 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 don't actually exist or aren't there when I test them. Patients usually like to have a "diagnosis":

If a shonky alternative healer tells you boldly 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 doctor 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 a waste of money," you're likely to leave the clinic 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 aim to offer healing based on science and ethics. However, doctors must keep in mind that 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 address patients' fears and educate at every appointment. Uncertainty is certainly an art in general practice.

(A version of this post was originally published on the author's blog