21 December 2008

Managing uncertainty, ambiguity and complexity

Do you know what a doctor does? Probably you think you do. Quite possibly it seems a fairly simple job. The patient goes to the doctor. The doctor is highly trained. The doctor knows what is wrong with the patient and delivers the appropriate treatment. What could be easier? But it is not really like that. Even apparently simple things are not really like that. When one of the Grumble children injured his ankle and had to be carried home by his friends it might have seemed likely that it was more than a sprain but Dr G did not know and nor did Mrs G. When he continued to fail to weight bear Mrs Grumble took him to A&E. No fracture apparently. Then it was back to the orthopaedic clinic. Now why do you think that was necessary? There he was seen by a registrar who was dismissive even though he still could not weight bear at all. That would have rung alarm bells even to Grumble. But there was no fracture - apparently. Then the consultant came in. He pressed on one spot and poor young Grumble leapt into the air - or he would have done if he could have leapt. And he ended up having to have his bone screwed together. How could this have happened? Were all the doctors up until that point incompetent? It happened because even orthopaedics, even whether or not a bone is broken is just not that easy. The A&E doctor would have been very junior and, despite years of training, the SpR had had insufficient experiential learning. The consultant got the diagnosis in seconds because he had seen it all before. He had the mileage.

Move now to the GP's surgery where the poor doctor has to deal with absolutely anything that is thrown at him or the physician's clinic where clinical problems that the GP cannot fathom may be referred. The problems there are even worse. Sometimes it can be easy. Dr G remembers as a student being impressed when a patient whose fingers were clubbed came in with an abnormal chest radiograph . Within moments the consultant was as certain as he could be that the patient had lung cancer. The young Grumble might have been impressed but that one was easy. Often it is not like this. The outpatient clinic can be a real struggle. Sometimes the history has to be wrestled from the patient. Sometimes the history gives few clues. Sometimes there are too many clues. Easy it is not. And if you don't know what is wrong from the history, the examination is unlikely to help either. The mental effort you have to put in is substantial. A busy clinic is draining.

The managers of MMC failed to realise that medicine is difficult, that extensive experiential learning is essential and that it is not just a matter of acquiring competences and getting boxes ticked. Many cases are grey. Many cases are ambiguous. And, as patients get older and older, many more are complex. Doctors need to think on their feet from first principles. They need to cope with not always knowing what is wrong with their patient. They need to cope with ambiguity and complexity. They need to help patients and their relatives who cannot handle the uncertainty. None of us likes uncertainty.

Unfortunately those responsible for the management processes in the health service have also failed to realise just how difficult this all is. Not only has medical training degenerated into a tick box thing but the management of patients has headed the same way. ACS protocols are now the order of the day for every sort of chest pain. It's a wonder this approach is not killing people. Perhaps it is. But nobody worries if the protocol is followed. And, if it can all be protocolised, we do not actually need doctors at all. That anyway is how the thinking was going. But that's because few away from the coalface recognised what an enormous issue the management of uncertainty in medicine is and few at the coalface wrote about it. Yet every real doctor will known of the ambiguities, the complexities and the fogginess that forms an integral part of the practice of medicine - whether you are an orthopaedic surgeon, a GP or a grumbling physician.

While doctors have always known this, they haven't said much about it because they really didn't think they needed to. It has been obvious to us. It has been obvious we are needed. It has been obvious that we need to learn from sheer experience and that no course or simulator can make up for lack of experiential learning. But as the mistakes have gone on being made from those in charge who know so little we have now had to tell them what doctors actually do. It's sad this was needed. It is a statement of the bleeding obvious. But Sir John Tooke was right to ask for it because those in charge do not seem to understand the bleeding obvious. Well done, Sir John.


First On Call said...

An excellent post. It's frustrating working as a junior doctor, with so little clinical experience and such unrealistic expectations from patients, family memebers and even other health care workers. The art of history taking and examination and constructing an intelligent differential is being killed by working time directives, ABC protocols (that trust me, DO kill patients) and "run through" training. What are we getting in its place? Junior doctors who are not as well trained as their predecessors and are hiding their inexperience with arrogance. Our long-winded note-keeping is designed primarily to protect ourselves and the hospitals we work in from future medicolegal prosecution and sometimes gets more attention than looking after the patient in front of us. I hope we can stop the rot.

Jobbing Doctor said...

Dear Grumble.

Oh How I agree with you.

Have a star!

Amy Stringer said...

A statement on The Role of the Doctor has recently been released by a steering committee consisiting of the Medical Schools Council, the Department of Health, the BMA, Association of UK University Hospital, The King's Fund, PMETB, GMC and NHS Employers as a result of the MMC enquiry. The statement, which is supported by the four Chief Medical Officers and the Chief Nursing Officer for England, can be found at www.medschools.ac.uk/news.htm