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- Page navigation anchor for Embracing uncertainty to advance diagnosis in general practiceEmbracing uncertainty to advance diagnosis in general practice
The authors present a good discussion of the reasons why diagnostic uncertainty exists in general practice. However, it would be useful to get more of an argument as to why uncertainty needs to be 'embraced', and how this should be defined, rather that just tolerated or accepted.
There is also the issue as to whether there is always a need to achieve a diagnosis all the the time, in general practice. One reason could be that it would be wrong to rush to quickly to a diagnosis, and miss other features of the condition, or even misdiagnose it. another could be that achieving a diagnosis is not of prime importance in a particular clinical encounter, either because that the condition is minor or self limiting or because there are other more important issues for the patient or GP.
Competing Interests: None declared. - Page navigation anchor for Embracing Uncertainty to advance diagnosisEmbracing Uncertainty to advance diagnosisI am glad to see the focus on uncertainty and particularly diagnostic uncertainty being discussed in this journal following other recent discussions by Simpkin et al.1 Indeed, the ability to manage feelings of uncertainties and effectively manage them is central to:1. Patient (e.g. undergoing unnecessary tests),2. Clinician (e.g. suffering stress and burnout) and3. System (direct and indirect costs from 1 and 2) outcomes.So what to do about this issue? As Malterud et al.2 have, we chose to focus on one area of uncertainty, diagnostic uncertainty.3 Our work discusses how clinicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. We performed a review of the literature and found few existing studies focusing on this area of uncertainty and of those located, most had a focus on traits associated with or internal resources of primary medical care clinicians for managing diagnostic uncertainty and only one study which tested a training intervention. We go on to discuss our propositions for dealing with each of the three domains (cognitive, emotional and ethical) but concur with the response from Avril Danczak and Alison Lea for a focus on training and more widely as Simpkin et al. do, for a cultural shift within medicine to acknowledge and accept the i...Show MoreCompeting Interests: None declared.
- Page navigation anchor for Response to "Embracing uncertainty to advance diagnosis" Malterud et al.Response to "Embracing uncertainty to advance diagnosis" Malterud et al.
Diagnosis is a slippery, changing phenomenon, not a fixed object awaiting discovery. Sydenham originally described gout as redness, exquisite joint pain and inflammation, knowing nothing of laboratory tests. Does a raised urate level still count as gout? Or is it only gout if the patent actually gets a painful joint? We talk of risk factors as if they were diseases and make "diagnoses" of asymptomatic conditions such as Carcinoma in Situ. In the process, we conceal the blurred and fluctuating boundaries between health and disease.
The authors do not define the competences for managing uncertainty. Listening to general practitioners in training1 and in our book "Mapping Uncertainty in Medicine; what do you do when you don't know what to do?"2, we began to identify the core skills for managing uncertainty. Searching for the "right diagnostic tools" may be less useful than a range of generalist skills, for example patients with worrying symptoms prefer to see doctors with good listening skills.3
Furthermore, clinicians carry uncertainties beyond diagnosis. Uncertainty about diagnostic testing requires the application of specific skills such as test selection and managing expectations (we termed these networking skills). Arranging care plans generates different uncertainties, which may be partly resolved with negotiating skills such as shared decision making. Team-working skills are needed...
Competing Interests: We are the authors of the book Mapping Uncertainty in medicine; what do you do when you don't know what to do? RCGP Books, London 2016.