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									     “Deal or no deal”

Hannah, Daniela, Gill
        Deal or no deal…
 Would you have a logical order?
 Does this reflect how you deal with
  uncertainty in your daily life?
 Are you a risk-taker?
 How do you deal with uncertainty in
              Uncertainty ?
During our years at medical school, we were
  trained in detecting and treating diseases
  rather than dealing with uncertainty.
The result? We order lab and radiological tests
  to excess despite relatively high probabilities
  of normal results or, coincidentally finding
  abnormalities that do not relate to the
  presenting complaints
         Uncertain general
 Part of daily life
 Too much knowledge and scientific evidence
  to remember
 It is ever changing (fast!)
 Visited by patients in early and
  undifferentiated stages of diseases
 Complaints that reflect combinations of
  organic and psychosomatic origins
              Role Plays
Split into 3 groups
20 mins
Flip chart
    Why is there uncertainty in
In an ideal world:

Condition A + Treatment B = Outcome C

   BUT there is uncertainty at all stages of
    this equation – why?
                  A: The diagnosis

   Symptoms do not always present together in a textbook way
   Patients present in different ways at different stages of any one
   Reporting of symptoms is biased depending on how patients
    report them
   Patients may hold back symptoms they feel are “worrying” or
    overemphasize them
   Doctor error in diagnosis due to insufficient or misleading
   Inconclusive test results
   Ease/availability of different tests
   Patient refusal of tests
           B: Which treatment?

   Evidence base
   Experimental treatments
   Patient preference
   Preconceived ideas or experiences regarding
   Alternative therapies
   Postcode prescribing
   Private vs. NHS treatment
               C: The outcome

   Variability in disease response to treatment
   Patient understanding of treatment plan
   Patient compliance
   Variable support networks to help patients
    through difficult treatments
   Differing expectations and perceptions of
   Presence of other, occult, disease which
    interacts with A or B to alter predicted C
PLUS, impacting on each stage of the
 above is the actual relationship between
 the doctor and patient and the variability
 in doctors personality types
Can you think of personality traits in
 yourselves as doctors, that affect how
 you deal with uncertainty???
 Highly self-motivated
 Over working
 Driven
 Obsessive
 Determined
 Self critical
 Perfectionist
The above traits tend to make us more anxious
  about the inevitable uncertainty that we face
  when dealing with patients
  Uncertain phrases/ actions
What do you use?
“I haven’t come across this before”
“I don’t know”
Asking a nurse for advice
“Lets see what happens”
“I’m not sure about this”
Used a book to find out about a condition
Asked another GP for advice
“I think this might be…”
“I need time to find out more”
Used a computer to find out more
• “I haven’t come across this before”
• “I don’t know”
• Asking a nurse for advice
• “Lets see what happens”
• “I’m not sure about this”
• Used a book to find out about a condition
• Asked another GP for advice
• “I think this might be…”
• “I need time to find out more”
• Used a computer to find out more info
• “I haven’t come across this before”          5
• “I don’t know”                               2
• Asking a nurse for advice                    3
• “Lets see what happens”                      1
• “I’m not sure about this”                   6
• Used a book to find out about a condition    8
• Asked another GP for advice                 10
• “I think this might be…”                     4
• “I need time to find out more”               7
• Used a computer to find out more info        9
      Coping with uncertainty
   How do you cope?

   No right or wrong answers!
               1) TRUST

Patient in doctor – to keep up to date with
   knowledge, to seek help when
   needed, to listen to their needs and
   advise accordingly

Doctor in patient – to tell them all the
  relevant info, to adhere to agreed
  treatment plans
           2) HONESTY

 Freedom to be open about the
  limitations of ones knowledge/skills
 Acknowledgement of uncertainty to
 Willingness to research things we’re not
  clear about and call patients back once
  better informed
            3) AWARENESS

 Of the presence of uncertainty, both to ourselves and
  to patients
 Of the complexity of the uncertainty surrounding
  management of patients
 Of our own personality types and approaches to
  risks/ uncertainty
 Of what is important to our patients – their agenda
  and how much uncertainty they are willing to accept
 Of our own limitations
 That failure to some degree is inevitable – “Ever tried.
  Ever failed. No matter. Try again. Fail again. Fail
           4) KINDNESS

If we treat people with compassion and
   kindness we will better understand their
   uncertainties and thereby be more able
   to manage them and accept them
     So…Deal or no deal?!
Lets play
 An awareness of the variety of sources of
 The different types of uncertainty faced from
  the point of view of both patient and the Dr
 The impact of our personality types as
  doctors on management of uncertainty
 How we might manage uncertainty in clinical
  practice and on a personal level
“In this world, nothing can be said to be
  certain, except death and taxes”
                                   (Benjamin Franklin)

  Video…Finals fantasy by the Amateur

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