“In order to make progress, one must leave the door to the unknown ajar.” Richard Feynman
Some time ago I attended a one day workshop on teaching clinical reasoning. It was delivered by Dr. Art Nahill and Dr. Nic Szecket two physicians now calling Auckland home, and creators of the popular imreasoning podcast series. Along with some teaching tips and bias recognition exercises, we received an impromptu lesson in art appreciation. I was confused too…
An art educator from the QLD Art Gallery was invited to present a series of artworks. The images where clearly not medically related, nor did they have any discernible theme or relationship. With little contextual framework, it was unclear what the goal of the exercise was. We were then asked to tell her what we saw. It was at this point I began to feel uncomfortable.
I was struck by the lack of instructional detail around the exercise or any framework that might have been communicated by the learning objectives. This coupled with the intrusive awareness of my inexperience in art appreciation produced some unusual reactions.
Initially, I was critical. There clearly has not been sufficient thought gone into this session.
Then I was dismissive. I will just not invest too heavily in this session but perhaps the next will be more useful.
But these pictures just kept coming! How long must I endure this discomfort of not knowing what the hell is going on?
There were others in the audience who managed the uncertainty more productively. Some reached for an all-encompassing theory of what the artwork ‘meant’. There were others who categorised and itemised the elements they saw by colour, form, light and texture. Curiously there were some who appeared to be at home in the whole affair and even to enjoy it!
And the questions kept coming…. “tell me what you see. What do you think about that? How does that make you feel?”
As I sat there (all the exits were blocked) I began to imagine I was back on Thursday Island in the safety of the on call room taking a call from an new remote area nurse.
“I have a 40y female here who is well but has abdominal pain with rebound tenderness. She has been drinking.”
Initially, I was critical: That makes no sense. An experienced remote area nurse will be well versed in SOAP or ISBAR presentation of information. This was not the way I expect clinical information to be presented.
Then I was dismissive: She is well so I clearly do not have to worry. The rebound is likely a error. I searched for a theory of what it all meant “it must be alcohol related gastritis” Which allowed me some thinly veiled confidence to move forward in my management.
But my inexperience in early recognition of surgical presentations was forefront in my mind so just in case order everything and fly her in by rotary wing in the middle of the night for some imaging and formal bloods.
The disturbing truth is that there is nothing absolute in Primary Care. We are the collectors and distributors of undifferentiated presentations. However in remote indigenous medicine the uncertainties are more significant. We regularly make diagnoses without laying eyes or hands on our patients. We rely on the experience and skills of our nurses and health workers. We are the key masters for costly investigative and management pathways involving huge distances and time away from community. We are uncomfortably aware of the uncertainty around recall and reminder systems and other barriers to ‘follow up’ care of our patients.
The question then is not, how can we control for uncertainty, but how can we manage ourselves to allow for it, and even encourage it thereby promoting the curiosity it engenders. In this way we neither close the door too early, nor over investigate in our efforts to control for the uncomfortable silence of not knowing.
Evidence based strategies have been summarised neatly by GPSA, of most relevance are:
- Acceptance. Diagnostic uncertainty is inevitable in general practice. Its ok to not know.
- Identify the patients agenda. Building patient care around what the patient expects from the encounter changes the definition of a success.
- Employ decision making tools. What is the most common cause of this presentation and what are the most serious diagnoses that must be ruled out?
- Test of time. Patients that present early in their illness will not present classically. Give it time and arrange a saftey net.
- Share decision making. Involve the patient in your decision making and the uncertainty around it. Exchange information and available options before agreeing on a plan.
So thank you to Art and Nic, I may even visit an art gallery these holidays, though it’s still pretty unlikely.
Check them out at imreasoning.