19 December 2018

In the third instalment of our series on key professional competencies, Dr Chris Tiplady explores the subject of uncertainty and how to respond when you’re asked to make a definitive diagnosis in the face of limited evidence.

On one of my most memorable ward consultations, I was asked to see a patient because it was thought he had splenomegaly. Nothing unusual so far. But what made this patient stand out was the fact he’d had an ultrasound scan showing nothing out of the ordinary.

At the time, I dutifully went to the ward, wondering what they needed me for. There wasn’t a big spleen, of course – the team were just feeling abdominal muscles, easily confirmed by checking movement on respiration and lifting the head off the pillow – but it was great to talk with them about why they had asked me. They obviously thought I was an approachable spleen expert – and it was rather nice to be asked – but was I really better than an ultrasound?

Of course, like the doctors who called me that day, I have dealt with diagnostic uncertainty. I feel equipped to manage it, but in the past have sometimes done the wrong thing – not asking a colleague, not getting a second opinion – and rushed into a diagnosis that was eventually proven wrong.

Making a diagnosis can be difficult; we are all taught that our consultations should end with one (or even a list of them). We are trained to talk, question, examine, test and come up with something to explain what is wrong. Diagnoses are expected by our patients, our colleagues and ourselves. That pressure can lead to mistakes and the wrong – or unnecessary – treatment.

We have to be alert when things don’t feel right, when results don’t match what we expect or when patients don’t progress in line with our predictions. Here are some things I have learnt and put into practice to make sure my own uncertainty never puts patients at risk.

1. Don’t rush

As pathologists we are often pressured to make a diagnosis on scant evidence or material. Clinicians are also driven to make a diagnosis, sometimes forgetting what is actually important to the patient. Not every test or treatment will actually help – in fact, some may cause harm – and many interventions are not even evidenced based.

Encourage your colleagues to have conversations with the patient to make better decisions about their care. This will help to avoid tests, treatments or procedures that are unlikely to be of benefit. The Academy of Medical Royal Colleges describes this beautifully in its 'Choosing Wisely' campaign

2. When you don’t know, say you don’t know

Never worry about looking the fool. Pathologists are serious diagnosticians, but diagnosis is complicated and relies on clinical as well as pathological context. Rather than masking your uncertainties – or worse, ignoring them – share them. They will likely help the team looking after the patient. Try to understand what the clinical concerns are, what the patient’s worries are, what is most important now and what options are being considered.

Questions like these can help you push back if there’s pressure to pin down an outcome – a pathologist understands disease in a unique way and can offer real support and guidance while not actually committing to a diagnosis. As I mentioned in my blog on supervision, admitting when you don’t know is also important in fostering a support culture for trainees and newly qualified pathologists.

3. Listen to your inner alarm bells

If something doesn’t feel right, it probably isn’t. Step back when you feel those bells going off and re-evaluate. Ask a colleague to check your work or your report. Make sure you are also approachable to discuss unclear result with others. It works both ways and can save you making mistakes.

It is only a few weeks since a very kind colleague did this for me. He pointed out an error of omission I had made when following up a patient with anaemia and a paraprotein. I had not checked this patient’s serum light chains correctly, meaning I could have missed a diagnosis of myeloma. When I reflected on this error, I realised I knew something wasn’t right but just hadn’t done the right tests at the right time. It’s good to know he is looking out for me and my patients, and I can now make immediate changes to my practice and knowledge to make sure this doesn’t happen again.

4. If you are criticised, be kind to yourself, evaluate, reflect – and move on

Getting an email to say you got something wrong can feel awful, especially for trainees and more junior consultants. But people usually share critical feedback because they want you to get better. Be a reflective practitioner: look at the whole situation and consider what might have affected your decision-making. What was going on for you at the time? What else was happening in the department? What knowledge or support might you have needed?

Thinking this way not only helps your practice – impacting on patients – but it also helps mediate the initial sting of having made a mistake. The GMC has some clear and good guidance about reflection which I recommend.

5. Learn how to let go by handing over

I have heard of so many doctors waking in the middle of the night worried about their decisions, sometimes phoning in at crazy times to check on patients and their teams. When you find yourself doing this, consider talking it over with a colleague or supervisor.

We’ve all had difficulty letting go of a particular case or issue at some point, but for some it can become a recurring issue, leading to loss of sleep and anxiety. A lot of doctors ‘catastrophise’, always assuming the worst will happen, but we have to trust others. And, if you share your concerns and management strategies with the team and with patients, you will find that in the vast majority of cases people will manage without you.

6. Rush sometimes

This point is in direct contradiction to the first one (this is about uncertainty after all!):sometimes you do have to be quick. The rules or guidelines may not be right and you may have to adapt, to take into account extremes of age or a very complex social situation. Doctors and scientists train for years just so they can approach cases like this with flexibility and confidence. That’s what we’re made for.

This doesn’t mean you should disregard other good practice when under time pressures – particularly keeping communication channels open and transparent and putting the patient at the centre of your decision-making.

Medicine is a fantastic career and we are lucky to be part of so many lives and stories. Our humanity – that ability to care for and support others – can make us fantastic at our jobs, but we have to also recognise that, as humans, we are fallible. The doctors I met in the case of this patient’s (now slightly tender) abdomen were absolutely convinced he had an abnormally big spleen. But they did the right thing – they admitted they were confused by the test results and asked someone else, however silly they may have felt. If we can all be a little more like them, our practice – and our patients – will surely benefit.