How come breaking “good” news is so hard?

In one of Liam Farrell’s typically hilarious blogs, he relates the painful task of explaining that an elderly relative, instead of dying as expected, has perked up and is enjoying the company of her extended family who have flown in from their far flung lives across the world …expecting a death. ( The family are not best pleased that their well laid life plans had been interrupted by the false expectation of grannies death. After all they all had other things going on!

This got me thinking about why and how breaking good news and be just as hard as breaking bad news and sometimes gets us into clinical WDYDWYDKWTD moments.

Bad news means something that changes your view of the future for the worse; we easily recognise how a cancer diagnosis an abnormal smear or even an allergy could do that, But good news? Surely everyone is keen on that? As Dr Farrell discovered it all depends on the context and the way you tell it.

Doctors often keep their clinical reasoning thoughts to themselves; this can result in seriously crossed lines of communication with the patient. The doctor does a blood test to rule out anaemia and is relieved when the tests is normal. The patient hopes that the test will rule something in and is disappointed when the result is normal, perhaps saying, “so you still do not know what is wrong with me?” The clinicians good news is the patient’s bad news.

This conversation can put the clinician on the back foot making them feel uncertain about what to do next; jumping to a dysfunctional way out of uncertainty can lead to a reflex referral for “a few more tests”. Before long, a cascade of normal investigations follows, having the paradoxical effect of good news leading to increasing rather than decreasing anxiety in both clinician and patient. The search for a test result or radiological image that will define the problem can be a fruitless one, as many conditions in General Practice will inevitably remain poorly defined, purely symptomatic, or be at such an early stage that tests can be normal.

If testing creates an expectation that a diagnosis is there somewhere “waiting to be found” the patient will be harmed because investigation takes the place of treatment and care. Moreover, repeated testing in such a context is in effect evidence free screening, or fishing, for poorly defined purposes. The more tests done, the more likely one will be slightly abnormal; resolving this can lead to further tests or investigations accompanied by increasing anxiety and delays to active symptomatic treatments. However, the dysfunctional way out of an uncertain situation by doing more tests can be avoided if the need for breaking good news is anticipated and planned for.

The skills of “Breaking Good News are like the skills of “Breaking Bad News”; the application of generalist listening and consultation skills to the particular task of explaining and planning care. Before any tests or investigations are done the doctor needs to be clear about their purpose; rule in or rule out? (something common serious or treatable usually). It is best to avoid the dysfunctional testing whose purpose is “get this patient out of here”. The potential for normal results should be explained to the patient before tests are done, and the possible subsequent actions should be on the table at the beginning.

For example, in a patient with mild fatigue, normal examination and no red flags it could go like this;

“  Well, the good news is that your story and physical examination are reassuring , so in the first place we can hope that things will improve with time and if you get more regular sleep, a daily walk and avoid alcohol. Come back in a month if things not settling down”

( see and

It is all in the framing; not “I don’t know what is wrong”, rather “it’s good you seem to be healthy currently… let’s concentrate on what we might help”. In the longer run, positivity, combined with robust safety netting, is less likely to result in disillusionment.

In summary, when Breaking GOOD news…plan ahead, signal that good news is coming, empathise with the impact that the news is having, use positive language like “ healthy, normal” or “great for your age” and interpret any findings in the light of the patients own concerns. These approaches will naturally lead into plans that relate to the patient’s own specific needs. Always aim for a dialogue, so that your conversation develops guided by your expertise applied to the patients concerns. So, something to try in a consultation…BGN (Breaking Bad news) and sharing uncertainty with patients in a useful way. Perhaps these ideas might make it on to a Personal Development Plan near you!

Could this approach would have helped poor Dr Farrell?



“Do I really need a mastectomy?”

Thank goodness for 15 minute consultations. I knew my next patient, Pam, to be direct, articulate and easy to talk with and anticipated a straightforward encounter. However, checking her record, I realised things might be trickier this time.  Recent routine screening mammography had shown calcification, a biopsy had revealed low grade DCIS (Ductal Carcinoma in Situ). The clinic letter outlined the plan; mastectomy, then radiotherapy and 5 years tamoxifen.

I could see was worried; “Have you read the clinic letter? I am supposed to have a mastectomy next week”. She had been up all night googling breast cancer and DCIS. Various links had led her to concepts that DCIS is probably not actually a cancer, although thought to progress to cancer in some women. More information had led to more uncertainty and doubt. Hence her question

“Do I really need a mastectomy?”

In my own mind, I was not sure what to say at first. Sure, as a generalist my job is to care for the whole person while a partialist (in this case the breast surgeon) brings their own focussed expertise in the service of the patients health. If you are holding a hammer everything looks like a nail and of course surgeons are predisposed to consider the surgical options.

However, I know that the DCIS story is complex, constantly evolving and even controversial. DCIS is regarded as a precursor to breast cancer by many and usually referred to in this way in patients literature, such as cancer support websites. However,increasing the diagnosis of DCIS has not resulted in fewer late stage cancer diagnoses nor made much impact on breast cancer mortality rates, Women seem to live longer after mammographic diagnosis, but that is a survival rate…and mainly an effect of lead time bias. This happens if a disease is picked up early, before its usual clinical presentation. Then even if the person dies at the same age as they would have done without clinical detection, they appear to have lived longer after the diagnosis. Total life expectancy does not change in this scenario (and really that is what matters to most people).

Some consider that the term DCIS should become instead a type of IDLE (Indolent Lesions of Epithelial origin) to make clear that the progression to breast cancer is poorly understood and not at all inevitable. It would appear that we are now finding more indolent intra-duct lesions, that were simply invisible before modern techniques of investigation.

I could have taken the easy route and said “consult the breast specialist, they will give you the best advice”. However, I perceived that Pam was asking for something else entirely; she needed help in making her own judgement about the proposed treatment plan. This was a WDYDWYDKWTD moment for us both!

Using the Mapping Uncertainty in Medicine framework, the first question is do we know the diagnosis, and secondly is it just one doctor and patient or is there a group team or network involved? Although the surgeon is involved, at this point it was just the patient and myself discussing the issues. In that context, there was a WDYDWYDKWTD moment in the NEGOTIATING quadrant.

There are two things to think about here; what skills will help me, to help Pam, make a decision about her care? Secondly, what kind of doctor is Pam needing at this point?

To make a decision effectively we need to use Shared Decision Making skills, a formal set of learnable skills (just as breaking bad news is a learnable skill).  Linda and Ezekiel Emanuel (see Reference 1) have provided a useful typology of doctors and that helped me decide what kind of doctoring might be helpful.

I could have opted for a paternalist approach ie “doctor knows best”. This can be vital in a fast moving, complicated situation. For example, a patient with multiple injuries will probably be grateful for a competent doctor who makes the right decisions, with explanations rather than shared decisions; the situation is life threatening and the doctors expertise is paramount. This was not the case in my consultation with Pam.

The informant doctor, in contrast, would give the patient all the information and let them make an “informed choice”. Pam had lots of information, from the surgeon and from Dr Google…and yet she was not really any closer to making a decision she felt comfortable with. She was informed, but could not make a suitable choice.

Going beyond informed choice needed an interpretative doctor, who shares information with the patient, also guiding the decision making, using expert knowledge, while incorporating the patient’s values and priorities. This approach is usually called “Shared Decision Making” and seemed most appropriate here.

However, a deliberative clinician may go even further than the interpretative clinician by helping the patient to explore and examine the health related values “that can be realised in the clinical situation”, and which of those values are “more worthy and should be aspired to”. In this situation the clinician is acting more like a teacher or friend; engaging in a dialogue about what values are most important to the patient at the time, and even indicating what decision about medical care would be “admirable”.

How did Shared decision making skills (SDM) enable Pam to make a decision? There are several components to SDM; it begins with building an effective doctor patient relationship and understanding where the patient is coming from. So we talked about how Pam felt about screening and her diagnosis, what her personal aims for life were and how she viewed the effects of invasive treatments, mutilating surgery such as mastectomy, DXT and long term therapy. I asked about other aspects of Pam’s life; her family, relationships, work commitments, aspirations and plans. Genuine interest and respect for patients own experiences as unique individuals, builds trust and builds a strong rapport; this allows even difficult matters to be discussed openly.

The next three phases of SDM are Team talk, Option talk and Decision talk.

Initially, Team Talk clarifies that there is a decision to made, the extent to which the patient wants to be involved in that decision, and emphasises that decision making will be a team process with the doctor and patient working together. Thus, expert input and honouring the patient’s own views are combined (Reference 2). Pam did not passively accept the surgeon’s conclusions; she wanted to be involved.

We then moved to Option Talk; identifying and discussing the various options. These could include watching and waiting, getting more information about options from the surgeon, (for example, considering local excision rather than mastectomy), deciding whether tamoxifen was a suitable long term treatment etc.

Finally, moving to Decision Talk meant helping Pam to explore and make a decision based on her personal preferences.

In the end, the key outcome was not a final decision but rather a change in approach. Firstly, Pam realised that the decision about mastectomy was neither inevitable nor urgent; DCIS is not an emergency nor a clear cut cancer. This gave her confidence to take some breathing space, to think things over, to discuss with trusted friends and family, to see how the proposed actions fitted in with her own life. What was she really hoping for? Certain cure? (even mastectomy cannot offer that as DCIS is a marker for increased risk of breast cancer), fewer trips to hospital in the longer term? avoiding surgery? Pam also began to see her GP as a longer term ally through illness, a guide to the options and even as a go between. We discussed how writing to her surgeon or a further discussion with them, might clarify the range of potential treatments. We arranged to meet again, after time for reflection.

Some decisions do not fit into tidy algorithms; being comfortable with the messy uncertainty of life and helping patients to also understand and accept the uncertainty inherent in things, is one of the joys of being a generalist. When the science is changing and evolving faster than clinical practice it can be especially hard to share those uncertainties with patients, especially when evolution of thinking seems to suggest stopping doing things (like not doing back X-Rays for musculoskeletal pains, or mastectomy for DCIS). Taking a wide view, stepping away from paternalist or informant positions and work things out alongside the patient will enable both doctor and patient to bring what they know best to the consultation.

So longer 15 minute appointment was welcome. I went home still pondering the complexities of her choice.


Reference 1

Emanuel J Emanuel L 1992 Four Models of the Physician-Patient relationship JAMA 1992 267 no 16 p 2221-6

Reference 2

Elwyn G et al Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems. Ann Fam Med. 2014 May; 12(3): 270–275.


“Could this be a DVT?”


Deep Venous Thrombosis is an important condition; pain and swelling are troublesome and long term damage to the venous circulation is possible. Behind every doctors concern about possible DVT, lies a bigger worry. What if DVT goes on to cause a Pulmonary Embolism? PE gets a bad press: the ones we know about can cause bad breathlessness, haemoptysis and even sudden death. However, increasingly sensitive tests show more, and even more minor, PEs than we could ever know about before. This raises a new question; are we over diagnosing emboli? Perhaps it is part of the lungs job to filter out stuff, including small non-significant clots?

So a pain in the calf can cause doctors quite lot of worry.

This uncertainty was to the fore when Brian B arrived with pain his left calf. He was not sure how it happened, perhaps a rugby injury. He smokes 15 a day, and has just returned from a weekend rugby trip to France (via long train journey). He saw the rugby club doctor ui France who did a D Dimer, which was slightly raised at 350 (normal D-dimer result is less than 250 ng/mL DDU) He didn’t discuss the result much because Brian wanted to get home. Asked about his concerns Brian said “my grandma has just had a lung clot and she is very ill. Could this be a clot in my leg?

Examination showed normal pulse BP and O2 SATS, chest normal. His leg was mildly tender, but there was no actual swelling. While a senior clinician might use a “gestalt” also known as a hunch or a heuristic to say “mmmm DVT pretty unlikely” it is hard to ignore an abnormal result when you have one. So what to do next? Can we still be reassuring? This type of WDYDWYDK is an example of a problem in the ANALYSING QUADRANT. The diagnosis is the issue and at present there is not network group or team involved. So what can the clinician do in these confusing circumstances?

A dysfunctional way out would be to simply send the patient away…to the Accident and Emergency department for Doppler’s to the calf, and maybe even imaging to “rule out” a PE,. This would certainly move the problem away from the GP consulting room yet may expose the patient to radiation, further tests and definitely a lot of inconvenience and worry, even if all turns out to be normal.

So how good is the clinicians “hunch”, that all is well? We can back this up by using appropriate scoring tests…in the age of google they do not have to be committed to memory, the ones relevant here are the wells score     and the PERC score (Pulmonary embolism Rule out Criteria)  both of which turn out to be normal ie Zero. So he probably did not need that D dimer in the first place.

Does this matter? Well, taking a more considered “worked out” view could save the unnecessary cost of a D-dimer test, prevent further unnecessary imaging and thus decrease radiation exposure from CTPA/CT venography. Furthermore, avoiding referral allows care to be given more quickly to others in the “queue” who may be in greater need. Referring could divert our focus too far in the direction of “ruling in or out a DVT” when there are other causes to consider. In this particular situation the possible causes of a raised D Dimer may related to his smoking or a recent influenza attack, thus it may be just as important to check his chest carefully for infection as it is to check for PE.

Decision scores and rules can be tedious and tick boxy at times; however, applied judiciously they can be a great help in a “what do you do when you do not know what to do” situation.

“I want to be a doctor but what if I just get burned out?”

Modern medical practice can be stressful and workloads feel like they are becoming heavier each day. Many doctors feel like this is a WDYDWYDKWTD (What do you do when you don’t know what to do?) situation; they really want to be doctors, yet worry this will be a fast route to burn out and misery.

This is really a team-working issue; although we have to do our own work, we contribute in a context, which can help or hinder us. Inspired by a recent column in the British Journal of General Practice “Ten Commandments for the resilient practitioner” (see ref 1), I chewed over the idea that there might be some values and attitudes which nourish and restore us. I think we will be successful, happy and effective when we;

CHERISH our humanity and that of our colleagues, family and patients; attend to basic needs like food, and also to what is unique and valuable about all of us.

CONNECT with others in our work, and in our community (colleagues, patients, family); we survive and thrive in relationships that we nurture, and which nurture us.

Be COLLECTIVE not individual. We are stronger together, its not just about “look after myself” but also “look after each other” and “work together”.

COOPERATE to devise systems and responses to pressure, that use the collective power of everyone working together; re-imagining, resisting, reinventing, re-engineering things. This makes work easier, better, safer and is better done collectively.

CO-CREATE the narrative of what happens, do not just be the recipient of stress/instructions/other peoples ideas; create and proclaim the true value and meaning of our work for ourselves. Working for something we believe in brings happiness.

CONFER with others; daily about work, successes and failures, also in education (talking is better than e learning), a trip to a conference can be energising and inspiring and makes for better CONNECTIONS.

COMMIT by being there. Long term relationships with colleagues are enriching and so are long term relationships with patients.  CONTINUITY brings satisfactions that can outweigh many stresses. CARE and be KIND to yourself and others.

CELEBRATE what works, the connections and values that sustain us, and remember that ours is a tough gig…disease, suffering and death are our daily business,just as prevention, healing and support are too.. THIS IS IMPORTANT STUFF and will be hard, especially when starting a career. Connecting with others, cooperating and celebrating makes us stronger, more effective (and we will have a lot more fun).

Reference 1) Ten Commandments for the resilient practitioner 

Simon Tobin, and Neal Maskrey

“Is this a pain in her jaw or a pain in my neck?”

In textbooks, guidelines and letters from specialists to generalists, life can seem clear cut. Symptoms, signs and tests all mesh together; a diagnosis appears. Everyone is relieved, except the poor patient who must wrestle with the consequences.

In Primary Care, it is not like that; patients may come with some, any, none or all of the symptoms of not just one, but several conditions. The ANALYSING quadrant of the Map of Uncertainty in medicine can help here. This addresses the WDYDWYDKWTD moments that arise when one doctor and patient are working together and they still don’t have a working diagnosis.

Agnes is a 36 year old kick boxer. She often competes and accepts the bumps and bruises that follow. She ignored an achy pain in her left jaw for a few days, putting it down to a fall in a bout she lost. It didn’t get better, she started to feel unwell, with a slightly sore throat. A friend noticed a swelling in Agnes’ neck and recommended a visit to the GP.

This unusual set of symptoms may give the clinician a WDYDWYDKWTD moment! Is her jaw broken? Is the swelling an abscess, a haematoma, the start of a lymphoma? Why does Agnes feel vaguely ill? It is tempting to take rapid “dysfunctional ways out” here.  As she is not that unwell, reassurance that all will settle with time may seem appropriate.  An X-ray in the A and E department to rule out a fracture uses referral as a quick way out. When the X-ray is normal she will go home none the wiser about her problem. Avoiding a diagnosis and saying vaguely, “it’s probably a virus”, or giving an antibiotic “just in case” are other “dysfunctional ways out”.

Better to use the skills of accurate hypothesis generation, thinking rationally about the differences between ruling things in or ruling them out. Marshall Marinker famously characterised the work of the generalist as being to “marginalise danger, explore probability and tolerate or manage uncertainty” (reference 1)

Could the worst case scenarios here be ruled out?  The trauma cannot be discounted; is there a head injury, jaw fracture? Could the swelling be something serious, an early lymphoma perhaps?

As for probabilities, a fracture was not that likely; although stoical, Agnes would probably have sought help immediately if she had pain on eating, with swelling or bruising over the jaw. The neck swelling may indicate inflammation; is there a local infection? Or are there, as yet unnoticed, swellings elsewhere, in the axillae, groin or liver?

Clinical reasoning can help in deciding where to go next Doctors are keen to rule things OUT, because it reduces worry about serious issues, if they can be reasonably ruled out. Patients are naturally keener for answers and would like to know what has been ruled IN. Examination helped here.

Agnes was fully functioning and alert and had had no period of unconsciousness or head trauma. With no bruising or localised tenderness over the jawbone it was reasonable to “rule out” trauma as the cause for her current problems.

The neck swelling felt like a reactive lymph node and the absence of other enlarged glands, spleen or liver, made a lymphoma less likely. This left some inflammatory possibilities. Careful examination of Agnes’ face revealed a few subtle pinky red spots, all on the same side of the cheek, her skin being otherwise healthy. The ears and throat appeared normal and Agnes repeated that she was not her usual fit and active self.

Could anything be ruled IN? The spots were nonspecific. Pinkish, small and perhaps a bit tender. Was the gland in the neck reacting to an infection there and if so what kind?  The malaise and sore throat could indicate some kind of mild viral process, but that would not explain the spots nor the unilateral lymph nodes. Perhaps the pain was early shingles.

So in the WDYDWYDKWTD moment, what could the clinician do next? When things are not clear cut, follow up and reassessment are powerful diagnostic tools for managing uncertainty proactively. When handled correctly, this can build a strong doctor patient relationship and therapeutic alliance.

When these thinking processes were articulated explicitly with Agnes, she was happy to accept some pain relief and an early telephone review. 36 hours later her face was looking awful, “as you said doctor, things might change quickly”. When she returned, the diagnosis became obvious; there was a patch of shingles across her cheek.

Using explicit reasoning skills and timely reassessment, unnecessary X-rays, antibiotics and an Accident and Emergency attendance were avoided. Uncertainty is an important sign in clinical practice; holding uncertainty and working through it methodically can yield effective results.

  • Marinker M. Medical Audit and General Practice. London 1990

“Are we letting her starve to death then?”

A carer in a nursing home asked this question on seeing Mrs J, an 82 year old lady with Alzheimer’s disease, push away food and clamp her mouth shut when offered a drink. Mrs J had been deteriorating for many months. Thin, bed bound, incontinent, unable to speak except to grimace or occasionally shriek, she needed help with all activities of life, able to do nothing for herself. Her appetite, never huge, had gone entirely. Now she was refusing everything, pushing carers away when trying to feed her, turning her head away when drinks were brought to her mouth. The staff were having a “What Do You Do When You Don’t Know What To Do” moment, looking to me for an answer; I felt I was having a WDYDWYDKWTD moment of my own.

Effective Palliative care can be tricky; knowing when palliation turns into end of life care, even harder. Could a structured approach to uncertainty help me here?

Mrs J’s care involved both diagnosis and management issues. The types of uncertainty here were ANALYSING (what were the diagnoses?) and TEAM-WORKING (arranging the right care with a group team or family) because Joan lacked capacity to plan or negotiate care herself, except perhaps, by refusing sustenance.

Using ANALYZING skills from the Map of Uncertainty in Medicine I first hypothesised and then ruled out intercurrent illness. Apart from the feeding issues nothing else had changed, examination was unremarkable. Although a little dehydrated she did not appear to have an infection, or be in pain, or have any mouth issues. Her dementia had been relentlessly progressive, with less of her old self apparent every week. Even offering her favourite foods did not help. Thus, I was able to rule in a diagnosis; this was a development of her disease, a sign that we were reaching the end stage of dementia, when even food is no longer recognised.

Then I turned to the TEAM-WORKING quadrant. This was not just about me and Mrs J.  Decisions involved her carers and nurses, and her two sons, who lived nearby. There are different ways to plan care. Pathways are for straightforward and slow moving conditions (a hernia repair in a fit 40 year old). Algorithms help when things move fast but are single conditions (childbirth), whereas pattern recognition helps more when things are fast moving and complex ( ITU, major trauma). This was a slower moving, complex situation which is also strongly preference sensitive, meaning care needs to be individualised to the person. Scenario planning is what’s needed here.

Fortunately, when Mrs J was admitted we had met with her family to do just that, and staff had regular updates with her sons as things deteriorated, creating an Advance Care Plan (1). Although saddened, they recognised that Alzheimer’s was taking their mother inexorably away from them. They wanted Mrs J to stay in situ; her last hospital admission had made her fearful, distressed and isolated on a busy ward. They also wanted to “Allow a Natural Death” (AND), a kinder and more accurate phrase than “Do Not attempt Resuscitation”. We had anticipated various scenarios including this one; how eventually the dementia could even result in her failing to recognise food and drink.

We called them once more, sharing the perception that Joan was approaching the end of her life; they were relieved to have this in the open having thought as much themselves. She was nursed tenderly in her own bed with her familiar carers and her sons visiting often. She slipped into a coma and died peacefully a few days later.

And no, we didn’t let her “starve to death”. She died from her Alzheimer’s disease. Emaciated patients with cancer do not starve to death, but die from their disease too.  Working with the whole team, recognising her family as a crucial part of that team, meant that, for Mrs J, the uncertainty generated by the pursed lips and refusal of drinks, resulted in careful planning and a peaceful death.

Her sons sent the staff a big bunch of flowers and thanked them for their care.


“Are you ashamed of yourself now?”

Fans of uncertainty may like to read the blog I wrote published by the BMJ at

Avril Danczak: Selling statins to patients

which addresses some of the uncertainties involved in making recommendations about statin treatments…..not so much a treatment, more a bet on the future?

“Why on earth has this 18 year old got enuresis?”

My colleague was facing a WDYDWYDKWTD situation. A young man came with his mother. He used to be continent at night when he was small, but now asked why he had been wetting the bed for the last 12 years straight and could the doctor please sort it out? Outside the familiar territory of enuresis in small children, things seemed  more puzzling.

Let us think this one through;

Is the diagnosis the problem, or, is the diagnosis known, but the treatment and care the issue? My colleague didn’t know how to treat the problem because the diagnosis was not clearly understood…enuresis is really a symptom not a complete diagnosis. This places us firmly in the ANALYSING QUADRANT of the Map of Uncertainty in Medicine.

With many common symptoms we rely on quick, intuitive thinking to help us work out what to do. This is sometimes called heuristics or “rules of thumb”. This approach was not working for my colleague, who seemed a bit paralysed. This can be due to internal factors (an unfamiliar situation perhaps, a lack of confidence that this “can be worked out”, or cognitive fatigue after a long day) or to external factors (too much work today, someone else needs the room). Sometimes patient factors play a part too and this patient seemed reluctant to give much history or explanation of the issues. Was there some other problem going on that he didn’t want to talk about in front of his mum?

Clearly, an intuitive approach wasn’t working, so how about a type 2 deliberative, methodical working out?  The psychological cost of switching from type 1 to type 2 thinking can be high. It takes a lot of effort to work things out systematically and this may not seem attractive if time, stamina or resources are in short supply.

In many situations like this clinicians resort to “dysfunctional ways out”…for example, “see a male GP”, or,”refer to someone else as soon as possible” or focus on only one aspect of the problem ( the bed is wet, let’s just use some anticholinergic tablets to dry up the urine) without fully analysing the whole problem. This is risky; these approaches may not solve the problem…the referral may go to the wrong service and be bounced back, or the anticholinergics may trigger side effects like constipation, worsening the problem and causing the patient to lose confidence or trust.

So what skills would help here? The first thing is probably to resort to traditional (Type 2 thinking) clinical reasoning, using a hypothetico-deductive method. Which system could be involved here and how would one tests the hypotheses that arise? Is the problem that the bladder can’t hold the urine, (too small? too much urine? Too deep sleep? Alcohol? Drugs? Infection?). Or is it that too much urine is being produced (diabetes? renal failure? Diabetes insipidus? Too much tea?) . Perhaps the control of the bladder by the nervous system is inadequate? (a neurological or sleep problem? Failure of bladder training? A psychological or traumatic event?)

In case the relevant questions tests and investigations do not help much, it helps to consistently maintain a wider view of the patient. What are the emotional, psychological and social issues here? How is the wet bed affecting him, or other family members? How has he come to consult now when the problem has been there for so long, unmentioned? Finding out how a typical night goes for him might reveal a lot.

This approach may yield a diagnosis, more likely it will yield several possibilities. If they can’t readily be resolved with Primary Care investigations then a referral may be needed….and then the skills of the NETWORKING QUADRANT of the Map of Uncertainty in medicine will come into play. We will turn to the skills of the NETWORKING QUADRANT another day….

“So what is the key message?”

What do you do when you don’t know what to do? (WDYDWYDKWTD)

“So what is the key message?”

This question cropped up during the discussion after a webinar about uncertainty in medical practice. Uncertainty is complex, pervasive and occurs in almost every consultation. So what is the key thing to remember?

Uncertainty feels very uncomfortable for clinicians, it makes them feel as if they are likely to get something wrong, to make a mistake, to be in error, because the way forwards is not clear. This discomfort can be so bad that clinicians try to escape it immediately by jumping to a decision. This could be by using pattern recognition (“this seems like another case of the flu that’s going round”) or by reflex actions (” this is tricky I will just refer on”). However, aiming for certainty all the time is fraught with difficulties. Doctors who are sued or referred to the GMC are sometimes surprised that the people who complain seemed ordinary and straightforward at the time….the clinician didn’t get a sinking feeling or a WDYDWYDKWTD moment. This may happen when allowing for uncertainty  seems too difficult, so the clinician immediately jumps away into some kind of comforting certainty about what to do next.

It follows that we need to notice uncertainty, value uncertainty and allow it to be an “inner alarm bell”.  Being uncertain need not be thought of a deficiency in the clinician, or as a fault in itself. Uncertainty is a guide, a reminder, to take a little time to reflect and ask oneself some questions.

“What is really going on here? Is this a problem with the diagnosis? Or is it a problem with how I am approaching the management of this problem?”

This pause for reflection should then allow the clinician to choose which skill might be most helpful. If there is a diagnostic problem it may be about creating the right hypothesis using basic clinical reasoning, or it may be thinking more clearly along the lines of “am I trying to rule something IN here or trying to rule something OUT?” and ensuring that the process is explained clearly in a dialogue with the patient.

If there is an issue about managing a known diagnosis, then it may be that specific negotiating skills are required (“what does this individual person need and want right now?), or, it may be about coordinating the activities of several team members…which is s skill in itself!.

So the key message is to notice and accept uncertainty and use it as a guide for reflection. Then ask “what kind of problem is this and what kind of skill will I need to solve it?”.  Expert practitioners do this kind of thinking rapidly, and may not explicitly explain how they were thinking… it seems to outside observation that they “just know what to do”. In fact, they probably noticed something uncertain, that didn’t seem quite right, paid attention to it and worked out what was needed next.



Mapping Uncertainty in Medicine

The practice of medicine gets more complicated every year,and it feels like everyone expects clinicians to “know what to do”and have all the answers. So what happens if a clinician is not sure what to do next? We call this the “What do you do when you don’t know what to do” moment or WDYDWYDKWTD for short.

Marshal  Marinker famously commented that the role of the Primary Care physician (or family physician) is “to tolerate uncertainty, explore probability and marginalise danger, whereas hospital specialists have to reduce uncertainty, explore possibility and marginalise error”(1) . Yet for most clinicians “tolerating uncertainty” is extremely uncomfortable. It makes us ask ourselves “am I about to make a terrible error?” or wonder if we are going to be criticised or sued. The result is that most clinicians try to minimise uncertainty because it feels so uncomfortable.

And yet, uncertainty does not go away and we all face uncertain situations everyday. Simply tolerating this does not feel like a satisfactory way forwards. But help is at hand from our book “Mapping Uncertainty in Medicine”. In the book we  explore ways to understand uncertainty in clinical practice,  to classify it into different types, and to identify which skills can be used to manage uncertainty in different types of situations, using a process called Mapping Uncertainty in Medicine or MUM for short. Its always good to have your MUM with you in a tricky situation!

(1) Marinker M and Peckham PJ (eds). Clinical Futures London: BMJ Books, 1998