Omission is easier to identify. Patients may ask, or more formal processes, such as clinical audit and guidelines, might provide clues. When considering possible omissions in the specific, there are considerations about whether the omission is a deliberate, considered decision specific to this particular individual; or inertia, when the intended objective was never reached.
Commission is a challenging issue. The pressure is to do something because we want reassurance (for the patient or the clinician), worry about medicolegal issues, or as Del Mar and colleagues raise, the perceived patient expectations or patient misperceptions about benefits and harms of alternatives.1 Commission often culminates with the superficially satisfying endpoint of a test, prescription or referral.
Choosing Wisely® is a project in the United States where professional colleges have identified certain things that physicians and patients should question. For example, in the case of simple syncope and a normal neurological examination, do not order brain imaging. As a general practitioner, an interesting observation is the overlap between each specialty’s list – the agreement between adult internists and family physicians on the limited role of imaging in low back pain; the agreement between family physicians and radiologists on not imaging patients with a low pre-test probability of pulmonary embolus, and the agreement between internists and radiologists on the lack of a role for pre-operative routine chest X-rays.2 Even if each specialty phrases it differently, there is agreement, even in the silos of the US healthcare system.
Avoiding errors of commission is more complicated when there are concerns about rationing care and cost saving motives. Combined with the ‘customer is always right’ service expectation, media messages and personal belief that the most advanced test most often ensures the best health, then the challenge is obvious.
Conceptually shared decision making (SDM) should be part of the way forward. This is when patients – in partnership with their doctor – are encouraged to consider the available options, the likely benefits and harms of each, to communicate their preferences and then help select the option that is the best fit.3 Patients tend to be less interventional than their doctors (eg. less likely to have PSA screening or an elective procedure) after participating in SDM.3
While SDM may be part of the solution to the imbalance between omission and commission, another challenge is developing a partnership that includes shared responsibility without the patient feeling abandoned.3 At times the outcome is not what was expected, likely or hoped for. When this happens, people react in different ways. Another challenge from a general practice perspective is that sometimes there are not numbers around risks and benefits, or clarity about the possible effects on a patient with multiple conditions who would not have been eligible for the trial that gives us the best available information. Decision making, shared or not, when many of the pieces of information are unknown or uncertain, is a particular challenge. Or, how to manage when the doctor feels the patient’s decision is wrong and the preferred plan needs medical facilitation. Or, if the decision is not concordant with best practice, how will that fit in with good quality care?
As every GP knows, nothing is simple! We aim to walk the tightrope – to provide personalised quality care that is in concert with the patient’s wishes, while not being overzealous with commissioning or too laid back to realise when omissions are occurring. Balance for good is what we aim for, even if we can feel very wobbly at times.
A deep breath in and out can often help. This issue of Australian Family Physician focuses on the respiratory tract. Tobacco is the scourge of the respiratory tract, Peters4 challenges us to look towards a day when there is the elimination of smoking. Hoy5 reminds us of the common occupational and environmental exposures that can effect the respiratory tract. Bronchiectasis is a condition we need to suspect to diagnose. Maguire6 discusses the condition and its management in detail, and Lim and colleagues7 provide structure for when patients ask the question: ‘Is it okay for me to ... ?’
So ... deep breath, think and aim for balance, and try to stay on the tightrope.