“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 scorehttp://www.mdcalc.com/wells-criteria-for-dvt/     and the PERC score (Pulmonary embolism Rule out Criteria) http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/  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

“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…..so 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.