09 September 2016 09:32:42

Managing uncertainty

When considering GP, there are just two prerequisites; you must like people and you must be comfortable with uncertainty.


Our new undergraduates arrived this week, brimming with enthusiasm. At some point in their stay we will discuss how they will choose the discipline they will spend the next 30-odd years of their lives doing.

When considering GP, there are just two prerequisites; you must like people and you must be comfortable with uncertainty. If you absolutely must know that Mrs Smith's potassium is in the acceptable range before you nod off that night, please become an anaesthetist instead. I like my anaesthetists just a little obsessive, don't you?

The uncertainty factor inevitably raised its head within three patients of our first surgery together. This patient was a young woman, with multiple vague symptoms and, underlying them all, a three-generation history of relapsing-remitting MS. Her MRI scan is next week and after one of my bright young things had hot-seated the consultation, I just wanted to check that she was prepared for the strangeness of a head and neck MRI. Of course, tears came.

The fear was, not of being encased in a metal tube and having to keep absolutely still while there are unpleasant loud noises right next to you, but of the scan being normal. That, at the end of the investigations and consultations, there will be no diagnosis.

This is not an uncommon fear. People don't want to feel 'it's all in their head' or worry that people think they may be malingering. For their clinician it is incredibly difficult to know where to draw the line when it comes to investigations and referrals. The NHS simply cannot afford for us all to do every test on every patient that walks through the door with a mixed bag of symptoms and current research estimates that this may be as many as one in six of our surgery lists (1).

What I imagine most of us do in this situation is to listen carefully, follow up anything remotely sounding like it could be serious, do some simple investigations where appropriate and safety-net, safety-net, safety-net. It's helpful to know your patient and what's happening beyond their immediate medical problems as I'm always surprised at how some apparently sensible folk fail to link distressing life situations with how they're feeling. That little bit of family gossip from their aunty Mabel may be hugely relevant and this is one of the reasons I love our little rural practice in its close-knit community.

The Royal College of Psychiatrists issued guidance in 2011 on how to manage those patients without a diagnosis - medically unexplained symptoms (2). This is defined as 'persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology'.

The key learning points sound like a checklist from a communication skills session, so should be bread and butter to GP colleagues:

  • People want to be taken seriously - show you believe them. Ask yourself and the patient "Am I hearing and understanding what you are trying to tell me?"
  • Doctors can make a difference to the patient's wellbeing even when their symptoms are unexplained. Concentrate on helping to manage symptoms and improve functionality.
  • Sometimes the only "therapy" needed may be the strength of your doctor-patient relationship - continuity of care and the long-term relationship helps.
  • Be pre-emptively reassuring, yet show you have an open mind and will continue to reassess. Explain rather than just 'normalise'.
  • Be explicit about your thoughts, your uncertainties and your expectations of referrals to specialist care and proactively communicate with other clinicians.

Sometimes you will get it wrong. This might be your own error of judgement, or someone else's, such as a misreported investigation result. That's a more difficult undergraduate tutorial. We'll keep it for another time.

References:

1. Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices. Taylor RE et al. Psychol. Med. 2012 http://www.ncbi.nlm.nih.gov/pubmed/21880165?dopt=Abstract

2. Guidance for medical professionals on dealing with medically unexplained symptoms; Royal College of Psychiatrists. Jan 2011.

http://www.rcpsych.ac.uk/pdf/CHECKED%20MUS%20Guidance_A4_4pp_6.pdf