Embracing (and discussing) uncertainty

Embracing (and discussing) uncertainty

'We live in uncertain times.’ Oft said, but I don’t think anyone can argue with that at the moment. A new virus which has spread like wildfire has brought a whole new dimension to what uncertainty looks like for us, both personally and professionally. Trying to deal with a new disease that, until 12 months ago, we knew literally nothing about has, I’m sure, been an uncomfortable experience for all of us. However, it has also reminded me what a brilliant profession we work in. Our primary care teams have dealt with the COVID-19 pandemic brilliantly, and we sometimes need to remind ourselves that, as GPs, we are experts in certain areas. Assessing, tolerating, and managing uncertainty is one of them.

The advent of the COVID-19 pandemic, with the resultant upheaval in terms of how we manage patients in primary care, has made me think a lot about uncertainty and how we deal with it. The pressures on the NHS have meant that managing our resources wisely is even more critical. But with this comes risk and uncertainty. I’ve never had too much of a problem with tolerating uncertainty in medicine, but what I probably have not been so good at over the years is discussing with my patients what that means for them. Trying to address this has been a focus of mine for a while, particularly since the changes with COVID and the increase in remote consultations.

Never is the issue of managing uncertainty more pertinent than when we are considering non-specific presentations that could be cancer. We know many (if not most) of our patients who present with cancer initially present with non-specific symptoms. How we manage the (majority) that present with symptoms that are unlikely to be, but could be, cancer is an age-old GP conundrum. So a recent BMJ study (BMJ 2020;370:m2651) caught my eye looking at unexpected weight loss and cancer risk. Yes, I know, ‘Rob tell me something I didn’t know - Asking about weight loss with possible cancer is day 1 at Medical School stuff!’ And yes, this study confirms what we know - unexpected weight loss is associated with cancer, but interestingly apart from the subgroup of men >50 who have ever smoked the PPV for cancer was <2%, unless other symptoms (e.g. abdominal pain), signs (e.g. abdominal mass) or investigations (e.g. iron deficiency anaemia) were present. So yes, unexpected weight loss is associated with increased cancer risk, but at <2% it is well below the NICE 3% threshold for urgent cancer investigation, so on its own can’t really justify urgent referral for potentially invasive (or harmful) investigations. Is there anything we can do to help reasonably rule out cancer? What about blood tests? Sadly as has been seen in other areas this study showed that blood tests in their own right are not sufficiently sensitive to rule out cancer.

So what is my take-home message from all of this? Well, it highlights the importance of embracing and dealing with our old friend uncertainty, and the need to be honest and open with our patients that we aren’t 100% sure what is going on, and giving clear safety netting advice. ‘No, I can’t find anything wrong yet, but that doesn’t mean it may not be the start of something more serious.’ ‘Just because your blood tests are normal does not rule out the possibility of something more serious developing.’ ‘We need to keep an open mind.’ ‘Don’t ignore new symptoms that develop such as……’ I’m sure you use phrases like these, or with similar themes, to help empower your patients to return appropriately if anything new develops, and not ignore that new abdominal pain they get just because they’ve ‘been given the all-clear’ by their GP.

So, as difficult as it may be, let’s continue to embrace and discuss the science of uncertainty with our patients because dismissing or hiding from it is a risky strategy.

Dr Rob Walker
30th September 2020

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