The nature of medical evidence and its inherent uncertainty for the clinical consultation: Qualitative study

Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL.
BMJ (online) (Impact Factor: 17.45). 04/2005; 330(7490):511. DOI: 10.1136/bmj.38336.482720.8F
Source: PubMed


To describe how clinicians deal with the uncertainty inherent in medical evidence in clinical consultations.
Qualitative study.
Clinical consultations related to hormone replacement therapy, bone densitometry, and breast screening in seven general practices and three secondary care clinics in the UK NHS.
Women aged 45-64.
45 of the 109 relevant consultations included sufficient discussion for analysis. The consultations could be categorised into three groups: focus on certainty for now and this test, with slippage into general reassurance; a coherent account of the medical evidence for risks and benefits, but blurring of the uncertainty inherent in the evidence and giving an impression of certainty; and acknowledging the inherent uncertainty of the medical evidence and negotiating a provisional decision.
Strategies health professionals use to cope with the uncertainty inherent in medical evidence in clinical consultations include the use of provisional decisions that allow for changing priorities and circumstances over time, to avoid slippage into general reassurance from a particular test result, and to avoid the creation of a myth of certainty.

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    • "Uncertainty about diagnosing is a typical characteristic of general practice [1,2]. Gut feelings and some important aspects of context knowledge, i.e. all a family physician knows about a patient apart from the signs and symptoms, are not discussed in traditional textbooks on medical decision-making, but often used by family physicians to support their diagnostic reasoning [3-5]. "
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    ABSTRACT: Background Family physicians perceive that gut feelings, i.e. a ‘sense of reassurance’ or a ‘sense of alarm’, play a substantial role in diagnostic reasoning. A measuring instrument is desirable for further research. Our objective is to validate a questionnaire measuring the presence of gut feelings in diagnostic reasoning. Methods We constructed 16 case vignettes from real practice situations and used the accompanying ‘sense of reassurance’ or the ‘sense of alarm’ as reference labels. Based on the results of an initial study (26 family physicians), we divided the case vignettes into a group involving a clear role for the sense of reassurance or the sense of alarm and a group involving an ambiguous role. 49 experienced family physicians evaluated each 10 vignettes using the questionnaire. Construct validity was assessed by testing hypotheses and an internal consistency procedure was performed. Results As hypothesized we found that the correlations between the reference labels and corresponding items were high for the clear-case vignettes (0.59 – 0.72) and low for the ambiguous-case vignettes (0.08 – 0.23). The agreement between the classification in clear sense of reassurance, clear sense of alarm and ambiguous case vignettes as derived from the initial study and the study population’s judgments was substantial (Kappa = 0.62). Factor analysis showed one factor with opposites for sense of reassurance and sense of alarm items. The questionnaire’s internal consistency was high (0.91). We provided a linguistic validated English-language text of the questionnaire. Conclusions The questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians’ diagnostic reasoning.
    Full-text · Article · Jan 2013 · BMC Family Practice
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    • "However, in our study the GPs registered certainty in their identification of the current problem in three quarters of the consultations. This high figure may be partly explained by the fact that physicians seem reluctant to disclose their uncertainty when talking to patients [27], and that GPs most often responded to ambiguous symptoms by ignoring them [28]. Since office consultations are characterised by time pressure, decisions have to be made quickly, both to categorise the problem and to take action. "
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    ABSTRACT: The aim of this study was to analyse the clinical decision making strategies of GPs with regard to the whole range of problems encountered in everyday work. A prospective questionnaire study was carried through, where 16 General practitioners in Sweden registered consecutively 378 problems in 366 patients. 68.3% of the problems were registered as somatic, 5.8% as psychosocial and 25.9% as both somatic and psychosocial. When the problem was characterised as somatic the main emphasis was most often on the symptoms only, and when the problem was psychosocial main emphasis was given to the person. Immediate, inductive, decision-making contrary to gradual, analytical, was used for about half of the problems. Immediate decision-making was less often used when problems were registered as both somatic and psychosocial and focus was on both the symptoms and the person. When immediate decision-making was used the GPs were significantly more often certain of their identification of the problem and significantly more satisfied with their consultation. Rules of thumb in consultations registered as somatic with emphasis on symptoms only did not include any reference to the individual patient. In consultations registered as psychosocial with emphasis on the person, rules of thumb often included reference to the patient as a known person. The decision-making (immediate or gradual) registered by the GPs seemed to have been adjusted on the symptom or on the patient as a person. Our results indicate that the GPs seem to recognise immediately both problems and persons, hence the quintessence of the expert skill of the GP as developed through experience.
    Full-text · Article · May 2012 · BMC Family Practice
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    • "How to respond to patients suffering with MUS, however, is one of the fundamental dilemmas of contemporary medical practice in primary care (Wainwright et al. 2006), which leaves the GPs adrift in an uncertain domain. As Griffiths et al. (2005) have shown, GPs prefer problem formulations, such as diagnoses, that have simple solutions as a way to create order in the midst of the chaos and confusion that their patients present. On one hand, doctors might find themselves frustrated by their inability to come up with a clear-cut diagnosis in medical encounters with patients classified as suffering from MUS. "
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    ABSTRACT: In encounters between general practitioners (GPs) and patients with medically unexplained symptoms (MUS), the negotiation of the sick role is a social process. In this process, GPs not only use traditional biomedical diagnostic tools but also rely on their own opinions and evaluations of a patient's particular circumstances in deciding whether that patient is legitimately sick. The doctor is thus a gatekeeper of legitimacy. This article presents results from a qualitative interview study conducted in Denmark with GPs concerning their approach to patients with MUS. We employ a symbolic interaction approach that pays special attention to the external validation of the sick role, making GPs' accounts of such patients particularly relevant. One of the article's main findings is that GPs' criteria for judging the legitimacy of claims by those patients that present with MUS are influenced by the extent to which GPs are able to constitute these patients as people with social problems and problematic personality traits.
    Full-text · Article · Mar 2012 · Sociology of Health & Illness
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