Managing uncertainty

Uncertainty in general practice can be a result of the following.

Inherent uncertainty in medicine

There is still much that is not yet fully understood in medicine, and the evidence base from medical research continues to grow and change.

Patients present to GPs early in the development of their illness

When patients come to GPs, their symptoms may still be vague or be symptoms of many potential conditions, or the connections between multiple symptoms may not yet be clear.1 In the absence of red flags, it can be difficult to make a clear diagnosis.

Moving from hospital training to general practice

There is still much that is not yet fully understood in medicine, and the evidence base from medical Patients tend to present to hospitals in the acute phase of their illness when they have clear and severe symptoms, and where there is access to immediate testing and the requirement for a full work-up.1 In contrast, there are far greater levels of uncertainty and ambiguity of symptoms in general practice, and this is combined with the need to make an independent decision during a short consultation.

For these reasons, most GP registrars experience an adjustment period when they shift from hospital training to working in a general practice.

Defensive medicine and over-testing

GPs who are concerned about missing a serious cause of a patient’s symptoms might arrange a wide array of unnecessary tests and investigations all undertaken ‘just in case’.^1–3 This imprecise approach can lead to over-testing, which increases the risk of:

• medical harms:
  • unnecessary investigations that may lead to potential harms, particularly if the investigations are invasive or expose the patient to radiation
  • false positives (especially if there is low pre-test probability)
  • a cascade of further investigations
  • overdiagnosis
  • treatment that is unnecessary and may even be harmful
• other harms:
  • financial cost to the patient if the tests and investigations are not bulk billed²
  • patient burden due to multiple tests and treatments (for more information on this concept,  see Minimally disruptive medicine for patients with complex multimorbidity).

Frustration and distress

Both the patient and GP can feel frustrated by a lack of diagnosis because both parties generally expect that a medical consultation will result in a diagnosis. Without a clear diagnosis, particularly if symptoms persist,  a patient and GP can experience a number of emotions and difficulties, as outlined by Dr Louise Stone.²

The patient might:

• struggle to make sense of their symptoms, particularly if the symptoms are painful and distressing, and reduce their quality of life
• feel unable to adequately explain their symptoms to their family, friends and work colleagues
• experience stress and anxiety from not knowing whether their symptoms have a serious cause  and will become worse, and whether there is any effective treatment
• face stigma or lack of understanding from others because they cannot provide a diagnosis,  which, for many people, legitimises their experience and establishes an illness as legitimate and socially acceptable
• experience difficulty in accessing required health and disability services or peer support
• feel frustrated at the GP’s inability to source high-quality evidence, clinical guidelines and  effective treatments.

The GP might:

• feel frustrated at the lack of high-quality evidence, clinical guidelines and effective treatments
• experience a sense of helplessness from not being able to provide an explanation or ease the patient’s symptoms
• experience a loss of confidence in their clinical decision making
• overly rely on tests and treatments (often to overcome their frustration, helplessness or loss  of confidence).

Patients can turn to treatments that are not evidence based

Frustrated by a lack of perceived progress, patients might feel dissatisfied with conventional medicine and seek treatments for which there may not be evidence of effectiveness. Not only could this result in ongoing symptoms, it may also expose the patient to potential harms.

Stress and burnout for GPs

Not being able to accept or tolerate uncertainty can be a cause for stress and burnout for GPs and  GP registrars.¹

Communicate clearly and openly with your patient

Effective and ongoing communication with your patient can help manage the uncertainty that you are both experiencing, and may help in leading you to a diagnosis.

• identify the patient’s agenda
• explain the uncertainty
• establish a safety net
• validate the patient’s concerns.

Each of these are explained in more detail below.

Identify the patient’s agenda¹

Ask the patient about their thoughts and motivations related to their symptoms so that you can identify what is most important to them at that point in time. A helpful acronym coined by Pendleton¹ is ‘ICE’ – ideas, concerns and expectations. Here is an example of ICE in practice, as used by General Practice Supervision Australia (GPSA):

• Ideas: ‘What do you think is going on?’
• Concerns: ‘What are you particularly worried about?’
• Expectations: ‘What were you hoping to get out of the visit today?’

Explain the uncertainty

Explain to your patient what is happening and what your thought processes are, documenting the conversations appropriately.

Where relevant, tell the patient:

• that the diagnosis is not clear at the moment
• about watchful waiting and why it may be required
• what to look out for, and under what circumstances they should return to you
• that they may need to return for a review at an agreed time
• what you want to rule out, and how you will do that
• how you will manage their symptoms in the meantime
• what they can do to manage their symptoms
• under what circumstances they should go to the hospital, and why.^3,4

Establish a safety net

• Always safety net for undifferentiated presentations that have the potential for serious illness.¹
• If there are a number of options available, engage in shared decision making. Consider using words like ‘we’ and ‘our’ so your patient feels like a partner in their management. For example, ‘Now that we’ve talked through the options available to us, where do you think we should go from here?’.¹ · If your patient wants to have tests or treatments against medical advice, consider:
  • arranging for a second opinion
  • politely declining with an explanation
  • seeking support from experienced colleagues or your medical defence organisation.

Validate the patient’s concerns

Make sure your patient feels listened to, that they were right to make an appointment with you to discuss their symptoms and that their concerns are validated.² Acknowledge that:

• the symptoms are real and distressing
• medicine has limits and the uncertainty is frustrating.

Explain that:

• diseases can be difficult to diagnose in their early stages or if the disease is rare, and that it might take time to reach a definitive diagnosis
• many tests will exclude diseases, but not necessarily identify the cause of the symptoms
• some patients have significant or distressing signs and symptoms but no completely defined diagnosis (eg chronic low back pain).²

Undertake a thorough review¹

• Take a comprehensive history and repeat this every time you see the patient.
• Perform an appropriate physical examination.
• Seek appropriate red flags, symptoms or signs that help identify or rule out a serious condition.
• Consider other sources of information, including previous medical investigations, specialist and  other health professional assessments and hospital records.

Consider whether test results will change your management of your patient

If the results of the test will not change how your patient is managed, then do not order the test.⁴

Please refer to the Royal Australian College of General Practitioners (RACGP) First do no harm resources  on over-testing and overdiagnosis for further information.

Manage the patient’s symptoms and provide lifestyle advice² 

Offer symptom relief.

• Consider practical support to address any disability (eg home help, workplace assessment).
• Encourage evidence-based non-drug interventions (for further information, refer to the  RACGP Handbook of non-drug interventions).
• Manage comorbidities.
• Encourage psychological care to address the impact of the illness and underlying issues that  may exacerbate symptoms.
• Address healthy lifestyle goals and continue to undertake preventive activities (for further information, refer to the RACGP Guidelines for preventive activities in general practice  [the Red Book]).

Consider referral as part of a multidisciplinary team

Because patterns can exist in different forms in different disciplines, referral as part of a multidisciplinary care team can be helpful.²

Continue to review the patient’s symptoms²

Review the patient’s symptoms at follow-up appointments. Consider different diagnoses if the symptoms get worse or change.

Because living with a severe, medically unexplained illness can be distressing, ask about the patient’s  mental health.

Accept that uncertainty is inevitable¹

Although uncertainty in medicine cannot be avoided, some doctors feel uncomfortable with it and want  to continue to seek answers even if a definitive answer might not be possible. Because this can be stressful for both the GP and patient, a greater acceptance of the inevitable lack of certainty in general practice can  be beneficial.

Reason analytically¹

Consider a more deliberate, analytical way of reasoning when presented with an ambiguous presentation. Some examples include:

• restricted rule-out (Murtagh’s process)
• clinical prediction rules
• diagnostic pause
• gut feelings
• test of time (mindful observation and waiting).

For further information, please refer to the GPSA resource, Managing medically unexplained symptoms  in general practice.

Use evidence-based resources¹

In addition to your own clinical expertise and the patient’s wishes, wherever possible include up-to-date systematic reviews and clinical guidelines in your decision-making process.

Australian Family Physician, Managing medically unexplained illness in general practice

Australian Journal of General Practice, Minimally disruptive medicine for patients with  complex multimorbidity

GPSA, Managing uncertainty in general practice guide

RACGP, 2022 RACGP curriculum and syllabus for Australian general practice