DECISION MADE:
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Navigating Uncertainty
Assertion not desertion
Patients consult with their GP to utilise their medical expertise to address issues where guidance may not be clear, or if their issues mean that published guidance doesn't specifically apply. As the first point of contact, this undifferentiated problem is bread and butter General Practice, and we must play an active role in steering the consultation through such uncertainty.
The GP is honest in her approach that she doesn't know exactly the best way forward.
Deferral to the patient doesn't help if the patient isn't sure what she needs, and she makes a choice of Gabapentin increase which isn't the most appropriate choice from a clinician perspective, having been stopped during Jean's admission, whileconsidering the likely lack of symptomatic impact of this controlled drug. Could there be an ulterior motive for her wanting to restart this?
SCA Feedback Statements
Ineffective approach or prioritisation in data gathering when presented with multiple or complex problems
The examiner felt you were insufficiently able to generate functional solutions for data gathering when the presentation was complex or multifactorial.
This may be about prioritisation; recognising the most pressing or important issues for this encounter and negotiating this with the patient. For example, if a patient has hay fever, longstanding headaches and bleeding on passing stool we might agree to focus on the latter today, offering time for the other issues in future.
Or this may be about seeing the bigger picture, rather than attempting an exhaustive evaluation of each of the symptoms in turn. For example, if a patient has symptoms in multiple bodily systems, might there be a unifying diagnosis? Or might exploring why all this is happening at once and what the patient is most worried about be more helpful than an exhaustive enquiry into each and every symptom, as long as this is safe?
Suggestion
Ensure you see plenty of complex patients, including those with co-morbidity. This may need triaging as new practice members often have more ‘book on the day’ single-issue consultations; complex patients may have a ‘usual doctor’ already. Discuss cases with your supervisor, as CBDs. Consider tutorials or peer study group sessions on complexity and negotiating priorities with patients.
Uncertainty including that experienced by the patient was managed ineffectively
Examiners felt that clinical uncertainty and/or that experienced by the patient was ineffectively managed.
It may be that time as a diagnostic aid was not used appropriately. Or that you were unable to tolerate or ‘hold’ uncertainty effectively. Or that management strategies used to respond to the patient’s uncertainty were not helpful.
For example: Another scan may not be helpful for a patient with medically unexplained symptoms. It might be reasonable to wait a week or so before prescribing for, or investigating a symptom that is likely to be self-limiting. On the other hand, someone who declines antenatal testing for Down Syndrome may need additional support and information while she completes her pregnancy.
Suggestion
Be aware of the literature surrounding over-medicalisation. Plan a tutorial or peer study group session on uncertainty in General Practice. Consider how uncertainty might be safely tolerated or responded to.