Врачи используют стратегии «наблюдательного ожидания» и «безопасной сети» для управления неопределенностью в первичной медико-санитарной помощи

“Uncertainty doesn’t come occasionally, singly, or in isolated categories. It’s the ocean in which we swim for most of our working lives.” – Dr John Launer, BMJ columnist. 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. 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. So how do doctors manage this professional challenge? READ MORE 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 “watchful waiting”, 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. Essentially, this is an agreed form of “doing nothing” for a defined period of time before rechecking the PSA blood levels and re-examining the patient. 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. The limitations of red flags were shown in research designed to see how accurate “alarm symptoms” 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. Coughing up blood produced figures of 8 per cent and 4.5 per cent respectively and for patients who experienced blood loss from the rectum, the risk of cancer was 2.7 per cent in men and 2.1 per cent in women. The good news from these figures is how few people with worrying symptoms have cancer. The bad news is how poor red flag symptoms are at predicting the risk of cancer and how many people must undergo invasive investigations to pick up the few with a malignancy. The doctor’s task within this uncertainty is to balance competing risks: missing rare but harmful diseases versus over-investigating common benign illnesses. According to a commentary in a recent Journal of the Royal Society of Medicine, “red flags have value within that balance but only when they remain embedded in reasoning that incorporates context, baseline risk, trajectory and the reliability of follow-up”. Patients have a key role to play in another strategy to deal with clinical uncertainty. Safety netting is a diagnostic and referral management strategy that works to ensure patients – especially those with potential signs and symptoms of cancer – are monitored throughout the diagnostic process until symptoms are explained or resolved, and all results have been acted on. Safety netting can be used to support patients with non-specific or low-risk symptoms by providing clear information and arranging timely follow-up, and to monitor persistent symptoms, even after negative test results. Every consultation carries a risk, because there is no absolute certainty of outcome. The key is to keep the door open and to review if new problems arise or “warning signs” occur. Education on what these are is part of dealing with uncertainty for the GP and the patient.