Gandalf ponders a management plan dilemma
My GP registrar’s body language suggested the tute was going poorly, although I blamed the topic: ‘Dealing with uncertainty’.
In retrospect, I could have stuck to medical examples, instead of opening with Gandalf’s dilemma about when best to attack Sauron.
‘Who’s Gandalf?’
My plot synopsis inexorably led us even further from doctor-patient interactions and into the dark tunnels of Moria. At which point I noted the aforementioned body language sending mixed messages—she was nodding, yet also pacing furtively backwards towards the door.
She stopped, embarrassed. ‘When can we discuss actual doctors having to deal with uncertainty?’
‘I’m not sure,’ I replied. Then, warming to the theme, added, ‘Deal with it!’
This should have been an easy topic for me. Some doctors are adamant. Others emphatic or forthrightly confident. Me? I am the master of uncertainty. Possibly.
The essence of general practice is having no idea what the next medical issue will be when the patient walks in the door. The essence of dealing with uncertainty is still having no idea when they walk out of it.
‘As an inherent sceptic,’ I explained, ‘my diagnoses, while brilliant, do tend towards vague motherhood statements.’
‘Thus, when a patient complains of a painful lower back, my eventual diagnosis, after a thorough history and examination, is “low back pain”.’
She was nodding and retreating again, but I expounded, ‘Who am I to be certain whether they have a subluxation, disc degeneration, or negative chi?’
I was enthusing now. ‘And, as for assuming my intervention of massage or gabapentin directly causes the pain’s eventual resolution, well…call me Dr Doubt!’
‘Post hoc,’ I boomed as sagely as I could, ‘does not always imply propter hoc!’
My gratuitous Latin had my registrar fearing I had merely switched from channelling Tolkien to Harry Potter, so she quickly –and somewhat unimaginatively—shifted the focus back to her own learning needs.
‘But uncertainty makes a GP’s job so difficult!’
Was I witnessing a watershed educational moment? I mounted my high horse to better the view.
‘And THAT,’ I gloated, ‘is why I rose to my calling and rejected all offers of careers where I would be forced to deal with certainty.’
‘Certainty? Such as?’
‘Well, like vascular surgery or…bomb disposal. The two careers where you have to urgently decide whether to snip the blue one or the red one.’
I always finish tutes with either a quote or a misquote, according to need. ‘Said Bertrand Russell – fools and surgeons are always so certain of themselves, yet wiser people so full of doubts.’
Finally, no doubt wisely, I let her out the door.
drjustincoleman 
When I was a junior GP trainee I remember being transiently confused but then inordinately proud of the assertion that the ability to tolerate uncertainty is a sine qua non for a good GP. (The ability to use Latin aphorisms is not.)
A good GP is a Bayesian master who can guide his patients through the fog without faltering.
A satisfied GP is one whose patients, from time to time, guide him or her through the fog.
Now that I’m an anaesthetist, there’s a fair bit less uncertainty to deal with… apart from “What is consciousness?” and “At molecular and neurophysiological levels, just how do anaesthetic agents work?”
The best way to deal with those uncertainties is drugs. For the patient, clearly.
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“A good GP is a Bayesian master who can guide his patients through the fog without faltering.”
Ah, another quotable quote from the Wise One.
Although others may prefer the more simplistic truth within “The best way to deal with those uncertainties is drugs.”
One day I’ll gather these into Chris’s Little Red Book.
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Aint this the blind leading the blind: the confused practitioner’s prescription for Neurontin in order to bring their patient to an equivalent state of dizziness. If only the GP had as much at stake as the bomb defuser, then perhaps more diligence would be applied!
When time is on your side, couldn’t you wait for some evidence base? The NHMRC recently thought it worthwhile splurging $618k for a trial of pregabalin for lower-back pain … seems a shame to pre-empt the report.
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I once had an intern (gosh, that makes me sound old!) who turned down a role as an elfin extra in LOTR because the intern year was starting…I just couldn’t warm to them. If all our examples, teaching, quotes and experience are limited to medicine, the world we offer those whom we hope to teach (and in turn learn from) will be very small indeed.
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Delighted you appreciate my dubious analogies, Anne. You and I could give each other affirming tutorials all day!
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