“ Deal or no deal ” … Uncertainty Hannah, Daniela, Gill

Deal or no deal … Would you have a logical order? Does this reflect how you deal with uncertainty in your daily life? Are you a risk-taker? How do you deal with uncertainty in consultations?

Uncertainty ? During our years at medical school, we were trained in detecting and treating diseases rather than dealing with uncertainty. The result? We order lab and radiological tests to excess despite relatively high probabilities of normal results or, coincidentally finding abnormalities that do not relate to the presenting complaints

Uncertain general practitioners … Part of daily life Why… Too much knowledge and scientific evidence to remember It is ever changing (fast!) Visited by patients in early and undifferentiated stages of diseases Complaints that reflect combinations of organic and psychosomatic origins

Role Plays Split into 3 groups 20 mins Flip chart

Why is there uncertainty in medicine? In an ideal world: Condition A + Treatment B = Outcome C BUT there is uncertainty at all stages of this equation – why?

A: The diagnosis Symptoms do not always present together in a textbook way Patients present in different ways at different stages of any one disease Reporting of symptoms is biased depending on how patients report them Patients may hold back symptoms they feel are “worrying” or overemphasize them Doctor error in diagnosis due to insufficient or misleading information Inconclusive test results Ease/availability of different tests Patient refusal of tests

B: Which treatment? Evidence base Experimental treatments Patient preference Preconceived ideas or experiences regarding treatments Alternative therapies Postcode prescribing Private vs. NHS treatment

C: The outcome Variability in disease response to treatment Patient understanding of treatment plan Patient compliance Variable support networks to help patients through difficult treatments Differing expectations and perceptions of success Presence of other, occult, disease which interacts with A or B to alter predicted C

PLUS, impacting on each stage of the above is the actual relationship between the doctor and patient and the variability in doctors personality types Can you think of personality traits in yourselves as doctors, that affect how you deal with uncertainty???

Doctors … Highly self-motivated Over working Driven Obsessive Determined Self critical Perfectionist The above traits tend to make us more anxious about the inevitable uncertainty that we face when dealing with patients

Uncertain phrases/ actions What do you use?

“I haven’t come across this before”

“I don’t know”

Asking a nurse for advice

“Lets see what happens”

“I’m not sure about this”

Used a book to find out about a condition

Asked another GP for advice

“I think this might be…”

“I need time to find out more”

Used a computer to find out more information

“I haven’t come across this before” “I don’t know” Asking a nurse for advice “Lets see what happens” “I’m not sure about this” Used a book to find out about a condition Asked another GP for advice “I think this might be…” “I need time to find out more” Used a computer to find out more info

“I haven’t come across this before” 5 “I don’t know” 2 Asking a nurse for advice 3 “Lets see what happens” 1 “I’m not sure about this” 6 Used a book to find out about a condition 8 Asked another GP for advice 10 “I think this might be…” 4 “I need time to find out more” 7 Used a computer to find out more info 9

Coping with uncertainty How do you cope? No right or wrong answers!

1) TRUST Patient in doctor – to keep up to date with knowledge, to seek help when needed, to listen to their needs and advise accordingly Doctor in patient – to tell them all the relevant info, to adhere to agreed treatment plans

2) HONESTY Freedom to be open about the limitations of ones knowledge/skills Acknowledgement of uncertainty to patients Willingness to research things we’re not clear about and call patients back once better informed

3) AWARENESS Of the presence of uncertainty, both to ourselves and to patients Of the complexity of the uncertainty surrounding management of patients Of our own personality types and approaches to risks/ uncertainty Of what is important to our patients – their agenda and how much uncertainty they are willing to accept Of our own limitations That failure to some degree is inevitable – “Ever tried. Ever failed. No matter. Try again. Fail again. Fail better”

4) KINDNESS If we treat people with compassion and kindness we will better understand their uncertainties and thereby be more able to manage them and accept them

So … Deal or no deal?! Lets play

Summary An awareness of the variety of sources of uncertainty The different types of uncertainty faced from the point of view of both patient and the Dr The impact of our personality types as doctors on management of uncertainty How we might manage uncertainty in clinical practice and on a personal level

“In this world, nothing can be said to be certain, except death and taxes” (Benjamin Franklin)

Thank-you! Video…Finals fantasy by the Amateur Transplants! hpqlLI