\u201cUncertainty doesn\u2019t come occasionally, singly, or in isolated categories. It\u2019s the ocean in which we swim for most of our working lives.\u201d \u2013 Dr John Launer, BMJ columnist. <\/p>\n
Dealing with uncertainty is an everyday reality in healthcare. Managing diagnostic uncertainty is a lifelong challenge for doctors. This is particularly the case in primary care.<\/p>\n
Most patients present to general practitioners with undifferentiated problems. And many symptoms are self-limiting. When you add in the low prevalence of serious disease in general practice, you face a perfect storm of uncertainty.<\/p>\n
So how do doctors manage this professional challenge?<\/p>\n
One of the methods of dealing with uncertainty is the use of time. This is appropriate with minor symptoms in the knowledge they are likely to resolve with time. Up to 40 per cent of patients who attend primary care clinics recover from a minor illness without specific treatment. It is also part of \u201cwatchful waiting\u201d, where you and the patient agree to monitor symptoms and plan to repeat tests after an agreed period. The technique is regularly used, for example, with men who have an elevated PSA, the blood test which, when raised, may indicate the presence of prostate cancer.<\/p>\n
Essentially, this is an agreed form of \u201cdoing nothing\u201d for a defined period of time before rechecking the PSA blood levels and re-examining the patient.<\/p>\n
Symptom flagging is another strategy. Doctors refer to red flag symptoms as ones that should alert the physician to the possible presence of cancer and other serious illness. Red flags are signs, symptoms or clinical features of a presentation that suggest a potentially serious or life-threatening condition. Red flags were designed to sharpen clinical attention when serious disease is possible but uncommon. They work best when used as prompts to modify probability rather than absolute rules.<\/p>\n
The limitations of red flags were shown in research designed to see how accurate \u201calarm symptoms\u201d were in diagnosing cancer in a general practice setting. It found the risk of a cancer diagnosis in the three years after a patient presented with blood in the urine was 8 per cent in men and 3.7 per cent for women.<\/p>\n