As a newly qualified GP I sometimes feel I’m walking a tightrope. Non-specific symptoms may represent early undifferentiated disease, yet overzealous blood tests and investigations can lead to patient harms.1 How can we get the right balance?
Testing to avoid missing something
Skill in general practice lies in dealing with uncertainty; inevitably this involves risk. Yet, risk management is an increasingly dirty word in a culture where health professionals face criminalisation for missed diagnoses2 with ‘zero tolerance’ for patient harms.3 This fuels a wave of fearfulness among GPs, who often use blood tests and investigations to reassure themselves that they are not ‘missing something’. Unfortunately this can lead to a vicious cycle; rather than reassuring ourselves, inconclusive or borderline results can generate increased uncertainty and anxiety.4 This in turn can lead to cascades of further tests, in what has been termed ‘investigation momentum’: the relentless pursuit to resolve uncertainty.5
Testing to ‘reassure patients’
We also may use tests to try to ‘reassure patients’. Yet recent systematic reviews have shown that normal tests make virtually no difference to patient anxiety.6 How often when we purport to be ‘reassuring’ our patients are we actually projecting our own anxiety onto them? In our qualitative study of inflammatory marker testing4 a GP explained the problem with this:
‘… GPs can underestimate the power of their own reassurance and sometimes actually what you’re doing is creating anxiety with the patients. So a doctor picks up on the patient anxiety, develops their own anxiety, chucks that back on the patient who then gets more anxious … where the clinician should probably make a sort of wider decision and fully reassure the patient.’
Doing something
Perhaps some of this stems from our own need to feel that we are ‘doing something’? We are trained to take a history, investigate, diagnose, and treat. Yet many of our patients struggle with psychological and social problems, for which we have no easy solutions. This can lead to a feeling of impotence. Do we sometimes use tests and investigations to help us deal with this sense of helplessness, in order to feel that we are ‘doing something’? As one GP we interviewed said:
‘They get a blood test as a sort of … gift to the patient, because it’s really hard to send them out the door without anything’.4
All of this can contribute to our ever-spiralling workloads, as Des Spence has recently highlighted.7 Another GP we interviewed described the impact:
‘I can’t remember what happened but I think I snapped … the path links were just too onerous, there were so many of them … I think that was the start of a very useful discussion with one of my colleagues who was doing similar things … And he said we, as a practice, ordered too many blood tests and we need to look a little bit more at that.’4
Doing nothing
So what is the solution? Perhaps next time we do a test we should stop and pause to reflect why? Is this the right test at the right time? Will our patient really be reassured? What exactly are we worried about missing? I remember vividly at the start of my GP training talking to my trainer about my feeling of helplessness, faced with complex psychosocial problems that did not fit the neat diagnostic categories I had been taught at medical school. His words stuck with me: ‘sometimes all we can do is bear witness to the misery of human suffering’. At the time it seemed pessimistic but over the years I have found myself repeating these words to myself and finding them uplifting. The act of bearing witness is important. We need to practise being there in the moment, listening to our patients, taking notice, and thinking, as Iona Heath beautifully described in her essay ‘The art of doing nothing’.8
- © British Journal of General Practice 2017