Embracing uncertainty to advance diagnosis in general practice

Malterud, Kirsti; Guassora, Ann Dorrit; Reventlow, Susanne; Jutel, Annemarie

doi:10.3399/bjgp17x690941

Cited by 33 publications

(20 citation statements)

References 11 publications

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“…Malterud et al have recently suggested that it is time for general practice “to develop theoretical, clinical, and practical strategies for embracing – not simply tolerating – uncertainty, instead of unsuccessfully trying to eradicate or suppress it” [24]. Our study underscores the timeliness of this proposal.…”

Section: Discussionmentioning

confidence: 57%

Dilemmas of medical overuse in general practice – A focus group study

Opdal

Meland

Hjörleifsson

2019

Scandinavian Journal of Primary Health Care

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Objective: To obtain first-hand in-depth accounts of overtesting amongst GPs in Norway, as well as the GPs’ perspectives on drivers of overtesting and strategies that can prevent overtesting. Design and setting: Four focus groups with GPs were conducted. All participants were asked to share examples of unnecessary testing from their everyday general practice, to identify the driving forces involved in these examples and discuss any measures that might prevent excessive testing. All authors collaborated on the analysis, conducted as systematic text condensation, using critical incident technique. Results: This study reveals two main positions regarding overtesting in general practice. In the categorical position there is no such thing as overtesting and GPs are obliged to perform extensive investigations on the suspicion that any person can carry a fatal disease, no matter how minor or absent their symptoms are. In contrast, in the dilemmatic position, the GPs acknowledge that investigations can cause significant harm, but still feel pressured to discover disease at the earliest opportunity and to meet patients’ demands. The GPs’ strategies for resolving this dilemma are often demanding and not always successful, but sharing uncertainty and fallibility with patients and colleagues appears to be the most promising strategy. Conclusions: Our study indicates that GPs in Norway experience a strong pressure to discover any instance of disease and to meet patients’ demands for investigations. One way of preventing the harm that accrues from overtesting is openly sharing uncertainty and fallibility with patients and colleagues.

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Section: Discussionmentioning

confidence: 57%

Dilemmas of medical overuse in general practice – A focus group study

Opdal

Meland

Hjörleifsson

2019

Scandinavian Journal of Primary Health Care

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“…High uncertainty and high stakes are characteristic of decisions in medicine [35]. Our results indicate that even when harm was unavoidable, regret can be devastating for clinicians.…”

Section: Resultsmentioning

confidence: 72%

Regret among primary care physicians: a survey of diagnostic decisions

et al. 2020

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Background: Experienced and anticipated regret influence physicians' decision-making. In medicine, diagnostic decisions and diagnostic errors can have a severe impact on both patients and physicians. Little empirical research exists on regret experienced by physicians when they make diagnostic decisions in primary care that later prove inappropriate or incorrect. The aim of this study was to explore the experience of regret following diagnostic decisions in primary care. Methods: In this qualitative study, we used an online questionnaire on a sample of German primary care physicians. We asked participants to report on cases in which the final diagnosis differed from their original opinion, and in which treatment was at the very least delayed, possibly resulting in harm to the patient. We asked about original and final diagnoses, illness trajectories, and the reactions of other physicians, patients and relatives. We used thematic analysis to assess the data, supported by MAXQDA 11 and Microsoft Excel 2016. Results: 29 GPs described one case each (14 female/15 male patients, aged 1.5-80 years, response rate < 1%). In 26 of 29 cases, the final diagnosis was more serious than the original diagnosis. In two cases, the diagnoses were equally serious, and in one case less serious. Clinical trajectories and the reactions of patients and relatives differed widely. Although only one third of cases involved preventable harm to patients, the vast majority (27 of 29) of physicians expressed deep feelings of regret. Conclusion: Even if harm to patients is unavoidable, regret following diagnostic decisions can be devastating for clinicians, making them 'second victims'. Procedures and tools are needed to analyse cases involving undesirable diagnostic events, so that 'true' diagnostic errors, in which harm could have been prevented, can be distinguished from others. Further studies should also explore how physicians can be supported in dealing with such events in order to prevent them from practicing defensive medicine.

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“…Third, it has long been recognized that doctors have to learn to handle the uncertainty that is an inherent part of any clinical practice. 30 General practitioners are familiar with uncertainty, even if they might disagree about the extent to which it should be 'embraced' 31 or avoided. 32 We recommend that uncertainty should be acknowledged and shared with the patient and that action plans are clearly communicated at the close of the consultation.…”

Section: Comparing Goldilocks Zonesmentioning

confidence: 99%

How wide is the Goldilocks Zone in your health system?

Ziébland

Rasmussén

MacArtney

et al. 2018

J Health Serv Res Policy

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In astrophysics, the 'Goldilocks Zone' describes the circumstellar habitable zone, in which planets, sufficiently similar to Earth, could support human life. The children's story of Goldilocks and the Three Bears, one of the most popular fairy tales in the English language, uses this metaphor to describe conditions for life that are neither too hot nor too cold and neither too close to the sun nor too far from its warmth. We propose that the 'Goldilocks Zone' also offers an apt metaphor for the struggle that people face when deciding if and when to consult a health care provider with a possible health problem. Drawing on decades of research in Denmark, England and Sweden on people's accounts of their experiences of accessing health care, this essay considers the ambivalence of health care seeking that individuals face in identifying when it is 'just right' to consult a general practitioner and the steps that health systems and individual clinicians might take to widen the zone.

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Embracing uncertainty to advance diagnosis in general practice

Cited by 33 publications

References 11 publications

Dilemmas of medical overuse in general practice – A focus group study

Dilemmas of medical overuse in general practice – A focus group study

Regret among primary care physicians: a survey of diagnostic decisions

How wide is the Goldilocks Zone in your health system?

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