Clinical Uncertainty in Primary Care

The Power of Colleagues

What happens when primary care clinicians meet together on set aside time in their practice settings to talk about their own patients? 

.....Complimenting quality metrics or performance measures through discussing the actual stories of individual patients and their clinician-patient relationships

In these settings, how can clinicians pool their collective experience and apply that to ‘the evidence’ for an individual patient?

.....Especially for patients who do not fit the standard protocols and have vague and worrisome symptoms, poor response to treatment, unpredictable disease courses, and/or compromised abilities for shared decision making

What follows when discussion about individual patients reveals system-wide service gaps and coordination limitations?

.....Particularly for patients with complex clinical problems that fall outside performance monitors and quality screens

How can collaborative engagement of case-based uncertainties with one’s colleagues help combat the loneliness and helplessness that PCPs can experience, no matter what model or setting in which they practice?

.....And where they are expected to practice coordinated, evidence-based, EMR-directed care

These questions inspired Lucia Sommers and John Launer and their international contributors to explore the power of colleagues in “Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement” and offer antidotes to sub-optimal care that can result when clinicians go it alone. 

From the Foreword: “Lucia Sommers and John Launer, with the accompanying input of their contributing authors, have done a deeply insightful and close-to-exhaustive job of defining clinical uncertainty. They identify its origins, components and subtypes; demonstrate the ways in which and the extent to which it is intrinsic to medicine…and they present a cogent case for its special relationship to primary care practice…‘Clinical Uncertainty in Primary Care’ not only presents a model of collegial collaboration and support, it also implicitly legitimates it.’’ Renee Fox, Annenberg Professor Emerita of the Social Sciences, University of Pennsylvania.

“This book is helpful reading for family physicians and essential for its teachers; it addresses a ubiquitious problem that we too often avoid as being too complex for discussion … . The book helps us speak honestly about an essential truth concerning primary care—that much of what we do is not exact science, cannot be taught as technique, and won’t be clarified through yet one more evidence-based guideline or clinic workflow … .” (John Muench, Family Medicine, stfm.org, July-August, 2016)

Despite doctors’ claims and aura to the contrary, diagnostic uncertainty is ubiquitous and needs to be looked squarely in the eye rather than eschewed or swept under the rug. This book does just that. Gordon Schiff, MD , Brigham and Women's Hospital /Harvard Medical Schoo, Bostonl

This excellent book challenges clinicians to come together to think and converse about every aspect of uncertainty so that it can become a source of delight rather than misery. Iona Heath, Past president Royal College of General Practitioners, London

The editors, who are experts in their own right, have assembled an outstanding group of colleagues whose writing illuminates the isolating effects of clinical uncertainty on practitioners and those with whom they interact. ..They also offer a variety of strategies, including Balint Groups, Narrative-Based Supervision, and Practice Inquiry, for approaching uncertainty with healthy acceptance and creativity. Richard Frankel, PhD, Indiana University School of Medicine

. . . beautifully demonstrates how collaborative discussions about the untold challenges that arise in real world practice can lead to clinical mastery. Gurpreet Dhaliwal, MD, University of California, San Francisco

It has often been lamented that there is no good up-to-date introduction to Balint work for people to recommend. Well, here it is! Lament no more! Andrew Elder, Consultant in General Practice and Primary Care, Balint group leader, London

This excellent book challenges clinicians to come together to think and converse about every aspect of uncertainty so that it can become a source of delight rather than misery. Iona Heath, Past president Royal College of General Practitioners, London

“As is suggested on ps.11-12, the increasing awareness of uncertainty both in the clinical and political context makes this a book of our times. I welcomed the sections which suggest that systematic and respectful discussions might be a useful way of hearing management and team problems through to solutions (p.82, or p.149-150), as well as tacking complex patient cases. Problem dynamics within teams are often played out around systems and practical resource problems, and the techniques suggested in the book may be a more fruitful way forward than the usual tetchy 'business' meeting. I was particularly impressed by Greenhalgh's four-dimensional taxonomy (p.41): as an academic GP myself, I both value the orthodox science that evolves the evidence base but recognise its limits - both at the level of the individual and in the realm of professional and personal judgement. This theme is picked up again in the sections on 'input and the blend' (p.196 onwards) , which gave some personal evidence of the motivating and healing potential of such conversations - a very important outcome if sustained, as so many health professionals are clearly burned out by the multiple demands and conflicting priorities of their work lives. The cross-cultural perspectives were also valuable, if only to make me realise there are places and periods in history where things may be 'better' - Tulinius' comments on Scandinavian sense of "sameness" would be a considerable contrast to the current U.K. tensions in the U.K.  Finally, I agree with you that action in the moment; as you portrayed in your Afterword (p.293 onwards) is often not conscious of the huge uncertainties in which we operate - but for others to learn, experts must unpick and make conscious and visible the ways in which they decide what to do. This book helped me, and will help others, to begin to conceptualise but also to practise our skills in using uncertainty to its best ends for patients and ourselves. “

Amanda Howe MD FRCGP, University of East Anglia, U.K., President-elect of WONCA, the World Organisation of National Colleges and Academies of General Practitioners/Family Physicians

Lucia Siegel Sommers is an educator and health services researcher with a 40-year history of working with clinician small groups. She holds an undergraduate degree from the University of Pennsylvania; a masters in social work from Bryn Mawr University; a doctorate in public health from the University of California, Berkeley and completed a 2-year fellowship in health services research at Stanford University. From 1994 through 2001, Lucia was a full-time faculty member in the Internal Medicine Residency Program at St. Mary’s Medical Center in San Francisco and Associate Program Director from 1997 to 2001. She is currently an assistant professor in the Department of Family and Community Medicine at the University of California San Francisco where she has taught medical students since 1996. Her published research includes studies focused on the effectiveness of medical audit, nurse-physician collaboration to improve care and reduce costs in hospitals and interdisciplinary care for the frail elderly in the primary care office setting.

John Launer is a family physician, family therapist, educator and writer. He graduated in English at Cambridge before studying medicine at London University. After obtaining Membership of the Royal College of General Practitioners with distinction in 1983, he worked for 22 years as a GP in Edmonton, north London, and continues to work as a part-time GP. In 1994 he completed training at the Tavistock Clinic as a family therapist and joined the senior staff there as honorary consultant in general practice and primary care. Since then his teaching and clinical work has drawn together ideas from family medicine and family therapy, with a focus on narrative and clinical supervision. John is an Associate Dean for Postgraduate Medical Education at London University, and has published five previous books as author or editor, including ‘Narrative-Based Primary Care: A Practical Guide.’ He has lectured and run workshops internationally, including in the USA, Canada, Scandinavia, Israel and Japan.