UNCERTAINTY
I Don’t Know What it is But I Don’t Think it’s Serious Dr Tim Crossley
(St Edmund Hall, 1974) Retired General Practitioner
There may have been a time when specialists were viewed as failed GPs, but it wasn’t for long, it must be admitted. Primary care, to coin a phrase, became levelled down to being ‘just a GP’. This in some regards is compensated for by a lowering of expectation, and a corresponding need from the patient to play the Diagnostic Certainty game. Never mind your opinion, I need a scan/test/referral/ procedure. Dr Crossley may be a nice guy but in the end I am not certain that he knows what he’s doing. Actually, when I asked, he said he couldn’t be 100% sure of anything. From the patient’s view the ground rules include first not revealing either their real worry or their goal, in precise terms, at least not immediately, for fear of looking foolish. The patient gets the first throw and now we’re all good listeners we give them that, for maybe ninety seconds or a little over. And if as a GP you genuinely can keep quiet that long, most of the clues will be there so the consultation can thereafter be gently focussed, maybe with some sort of physical examination though it is largely for show. We form ideas. We may even form conclusions. But we also know that making a diagnosis on clinical grounds alone is seen as suspect and leaping to it doubly so: double again if you are thought, without the confirmation and certainty of a test of some sort, to believe the presentation is more of psychological distress than definable physical illness. The path we seek to jog along is potholed and, in our haste to reach the end of it, we easily trip. Let us assume the patient is a child with a fever since this morning. Perhaps the little one isn’t drinking much, but he took some juice and perhaps has thrown that up in the car on the way. This ratchets the tension level nicely. There’s a non-
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The path we seek to jog along is potholed and, in our haste to reach the end of it, we easily trip.
blanching rash pointed out by the parent, but it is eczema. The patient is co-operative with being examined – not a good sign – but no specific localising features except coryza are discovered and urine dip unremarkable; we have an unwell hot toddler, a bit dry and no decent explanation for it. The first pothole is the assumption that we know what the parent is seeking. It is quite likely they fear meningitis especially if a case has been reported in the paper recently and want complete reassurance that it is not that; but they might fear something quite different, unexpected, even irrational. You have to tease this out obliquely, remembering rule one. And the clock is still ticking. But for now we’ll go with the meningitis anxiety. The second pothole is our uncertainty. We are tempted to say dismissively ‘it’s a virus’ implying until the recent past some self-limiting trivia – but patients are wise now, and so are some of us. This phrase won’t do, if it ever did. Worse, if the parent expresses their true fear aloud, we find ourselves hedging ‘Well meningitis is very difficult to diagnose in the first few hours…’ when we mean not that it is ‘very difficult’ but ‘impossible’. Whilst understandably protecting ourselves from the utterly unexpected yet keeping some professional dignity, we fail to deliver the news the patient’s parent wants and they will consider other options, like paramedics or a trip to A&E, or maybe ring their aunt who is an optician.
A one in a thousand risk feels “ fifty/fifty. A near certainty like catastrophic climate change, feels improbable.
We might consider explaining the size of the risk. The incidence of childhood meningitis in the 1980’s when I started in practice amounted to seeing a case about twice in a working GP’s lifetime. This is now much reduced, as the vaccines for Hib, Pneumococcus and more recently meningococcus were developed. The risk in our patient is thus vanishingly small so why not explain that? But this doesn’t help. Personal perception of risk is a fascinating field, where emotion and anecdote triumph over science. A one in a thousand risk feels fifty/fifty. A near certainty like catastrophic climate change, feels improbable. There are now whole academic departments of the public understanding of risk, and we need them desperately. Yet we still need to explain to the hapless parent, and fairly quickly as there’s a queue, that a) We understand their anxiety but do not believe this is meningitis b) We can make this judgement on the basis of history and examination alone c) Pursuing the diagnosis with say X rays, blood tests, urine culture, admission, would not help and, implausibly, make things worse with spurious results and hospital acquired disease
Oxford Medicine | Spring/Summer 2022 7
