There were a few episodes of How I Met Your Mother where Marshall and Barney had a ‘slap bet’ going – it was more about how Barney would cope (or not cope) with the uncertainty of not knowing where and when his next slap might be delivered by Marshall.
I was reminded of this when I had my own issues recently with urticaria of unknown cause – I seem to develop this once every 6-12 months after ingesting some unknown antigen. I break out into full-body hives unless I nip it in the bud with cortisone and antihistamines.
At least now, with my problem always beginning in the same way, with a hot itchy wheal on my knuckles and both wrists, closely followed by my knees and elbows, I can recognise the signs early enough to prevent it becoming too serious.
I have learnt to live with not knowing when this might occur, as it isn’t serious enough and doesn’t happen regularly enough for me to have formal allergy testing, or to even keep a food diary to try to find the culprit. Mostly when it happens I have had a concoction of ‘pizza with the lot’ or some other intricate dish with multiple ingredients. Could it be the star anise which was in a soup I hadn’t had before? I don’t think I will be getting my hands on any of that in my country supermarket to try out the hypothesis in the near future!
General practitioners are often faced with uncertainty and need to learn how to cope with this – whether it is dealing with not knowing what may walk through the door each day, or coming to terms with not being able to find a clear diagnosis for a patient, at least in some cases until an illness is allowed time to reveal its true nature. This can be frustrating, demoralising and scary, yet it is a part of our profession and it could rather be viewed as something that makes general practice interesting and challenging.
A particularly enigmatic presentation is that of ‘tiredness’. What a massive list of differentials right there! Going back to first principles and with a little help from the legendary Professor John Murtagh, there is a systematic way to approach this. Obviously a thorough history beginning with some open-ended questioning is paramount. What does the patient mean when they say they feel tired? Allow them to elaborate in their own words for a while. The challenge here is, in the words of Prof. Murtagh, to “diagnose such disorders quickly without extravagant investigation”. I feel this is in stark contrast to our over-dramatised colleagues in the US, lead by Dr. House, MD – it will be a sad day when I hear of a(nother) GP ordering a full-body MRI searching for who-knows-what. I certainly can’t see it becoming acceptable (or necessary) for me to go poking around my patient’s house and taking samples for laboratory analysis, or doing all of the specialty jobs from surgery, to cardiac catheterisation and pathology testing for that matter.
In my short time as a medical professional I have had to learn how to approach these uncertainties with confidence and an air of calm, knowing that in the majority of cases I will be able to determine the difference between a serious and benign cause of the presenting complaint. This is the case even if the outcome for a time is that you don’t know the cause of the symptoms, but what you do know is that so far there are no signs that the cause is a serious one needing urgent treatment – the plan can be to ‘watch and wait’. If a GP doesn’t learn to do this, then they will find themselves becoming increasingly stressed and dissatisfied with their work.
Utilising Professor Murtagh’s diagnostic approach model in his textbook John Murtagh’s General Practice, it is easy to ensure you do this:
1. What is the probability diagnosis? In the case of tiredness, this includes stress/anxiety/depression, viral/post-viral fatigue and sleep related disorders including sleep apnoea.
2. What are the serious disorders not to be missed? This list includes malignancy, cardiac arrhythmias and other heart disorders, anaemia of various causes, haemochromatosis, HIV infection and hepatitis C.
3. What are the pitfalls (often missed) disorders? For example, masked depression, food intolerances or malabsorption, chronic infections, drugs/alcohol, renal failure, pregnancy, menopausal syndrome, occupational chemical exposure, Addison’s disease, autoimmune disorders, and the list goes on!
4. Consider the ‘seven masquerades’ of depression, diabetes, drugs, anaemia, thyroid disorder, spinal dysfunction and UTI.
5. Is the patient trying to tell me something? In this case, the answer is “highly likely”!
This diagnostic approach serves as a guide for all of history-taking, physical examination and relevant investigations (i.e. NOT full body MRIs).
There is always going to be some uncertainty in medicine, like in many other areas of life in general. There is a saying that medicine is more of an art than a science, and it certainly can feel like that a lot of the time. The issue is how do we approach this uncertainty and deal with it, and how do we do this safely for the patient, as well as sustainably for our professional lives as GPs? We may not have all the answers as general practitioners, but we should at least know how to check for the serious disorders ‘not to be missed’, and where to turn for help when (not if) we need it.