NHS Practitioner Health Wellbeing Podcast
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NHS Practitioner Health Wellbeing Podcast
Managing Uncertainty in Medicine with Dr John Launer
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Practitioner Health Medical Director Dr Zaid Al-Najjar is joined by doctor, educator, and award-winning writer Dr John Launer to discuss uncertainty in medicine and healthcare - an aspect of the profession that can cause increasing feelings of stress.
Zaid and John cover uncertainty in providing care to patients, the importance of asking open questions, burnout and uncertainty, and ways to manage uncertainty, including reflective practice.
Read Dr John Launer's works here:
Reflective Practice in Medicine and Multi-Professional Healthcare
The Pluripotent Consultation, The BMJ
Finding Meaning in General Practice, The BMJ
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Welcome to this NHS Practitioner Health podcast. My name is Dr. Zayd Almajar. I'm a GP and one of the medical directors at Practitioner Health. And today I have a special guest with me, Dr. John Launer, who is here to talk about uncertainty in medicine and healthcare. Welcome, John. Thank you for joining us today. So for those of you who've not heard of John, or if I refer to you as John on this podcast too. So John is actually very well known, certainly in primary care and has written widely on the um topic of uncertainty in healthcare. So welcome, John. And you would you'd like to just say hi to the listeners and introduce yourself?
SPEAKER_01Yeah, thank you very much, Said. These days I introduce myself as a medical educator and writer. My background is as a GP. I was a London GP for close to 30 years, but I also uh trained as a family therapist. And for about half of my clinical career, I combined being a GP with being a family therapist part-time. And through uh the combination of trainings and skills, really, I became interested in um how how one could transfer ideas from one to the other, apply skills from one to the other, particularly in areas like supervision, narrative, and uncertainty.
SPEAKER_00Um, and um, when did uncertainty become a sort of special interest to you then? At what point in that career trajectory?
SPEAKER_01That's an that's a good question, Zaid. I think the answer is quite recently, probably only in the last few years it came into focus for me. I'd had an interest in narrative and in supervision, oh, for getting on for 25, 30 years now. And uncertainty was a feature of all of those with I suppose a lowercase uncertainty. But uncertainty as a topic in its own right with a uppercase U really only came into focus in the last uh maybe five or six years, and I realized how much of the work I'd done around narrative and supervision was actually applicable to uncertainty as a headline topic.
SPEAKER_00And I mean, the reason I ask is because certainly in the service we um see a lot of patients who um talk about their the difficulty in dealing with uncertainty in the course of providing care to their patients. And I was reading um a little bit about uncertainty in healthcare, and there's been some there has been some research saying that um around 25% of secondary care admissions feature diagnostic uncertainty, and that that that percentage is much likely to or likely to be much higher in primary care because patients present at a at an earlier stage in their illness or may not be unwell um at all. So it features um certainly it's a feature of of life in in medicine and healthcare. I suppose the only certain thing about medicine is that uncertainty is uncertainty. Um and a lot of the work that you have done as a uh in supervision and as a therapist is is helping others and and as an educator in managing uncertainty.
SPEAKER_01Um that's right. Um I I actually regard diagnostic uncertainty as the the the the the small tip of an enormous iceberg. Because of course there's there's uncertainty about diagnosis, there's then there's uncertainty about treatment, then there's uncertainty about treatment in context. Is this what the person wants, what the person is making an informed choice about? And then there's uh what I call a kind of existential uncertainty, which is um, am I completely missing the point? Is it not about the illness itself? Is it about the wider context of illness? What is what is being unsaid? And and then there's the sort of micro uncertainty of um have I just said the right thing? Has what I have just uttered um made things easier for the person in front of me or made it more difficult? Um, either way, what do I say next? How how do I retrieve it? What is the the best or the least worst thing to say next? So increasingly, I think I've regarded um an uncertainty as as at the core of everything that we do and necessarily at the core of everything we do.
SPEAKER_00Um it and when um you said diagnostic uncertainty is the tip of the iceberg, I think, yes, I think that's uh having heard you say that out loud, it it really does um make sense because although we hear a lot about diagnostic uncertainty with um with our patients, certainly when you said um the the the uncertainty about have I what did I just miss or what did I just miss with that interaction or have I said the right thing, all those all those uncertainties all play into the consultation that you have um with the patient. And um yes, it it took me back to lots of consultations I've had with patients over over the years. What what have I just missed there? What just happened? It's our sort of um question mark that you're left with at the end of the end of the consultation. Um is that something that you you find encounter a lot in educating and speaking to colleagues?
SPEAKER_01Yes, I I suppose it would hardly be exaggerating to say that at the core of my teaching and the colleagues that I work with who use similar approaches is is the idea of um celebrating uncertainty, of of moving into a mindset where you think actually uncertainty is is the ocean in which we swim all the time that we're working, and finding ways to notice that, to work with it, and to let things unfold rather than try and fix things. I mean, to a certain extent, doctors always have to focus on fixing things, but there is also a wider mindset which is fixing things within a wider understanding of how you can't fix it without the other person involved, and maybe they can't fix it either, and maybe fixing is a sort of emergent and collaborative process.
SPEAKER_00It is, I think, because we we are so um we are so trained to fix things that maybe makes this makes uncertainty so difficult to tolerate, I suppose. So um, and one of my questions to you today was uh do you think that um training nowadays um is suggests that tra uh doctors um are less tolerant of uncertainty? Do you think that the the the the way that we are trained nowadays means that actually uncertainty is not a good thing, it's not something um which we should um accept and that there always does need to be a a fix or a diagnosis and a plan?
SPEAKER_01Well, I think there are two elements to that side. I think the first element is to a certain extent medical training has always focused on the illusion of the right answer, uh, the only answer that you can possibly pursue. It's had the sort of, you know, the the detective plot um theme to it. And and I think uh maybe doctors are more addicted to that kind of vision of medicine than formerly, or maybe not, because it's always been around, as I say. Um I think the other element of it is we work in a climate now where clearly there is more questioning, there's more challenge, there's more litigation, there's more defensiveness. And that context reinforces the idea that um I have to get this right and I have to get it right in the only way, and that means looking up the best evidence and the nice guidelines and everything else. And it doesn't mean, although it very often should mean, just sitting back and listening to listening to the small cues and creating the opportunities that allow the other person to say, actually, you know what? That isn't the thing I'm mainly worried about, or it is the thing I'm mainly worried about, and everybody's telling me I should do such and such, but actually, can I have a bit of space to discuss with you whether I should do something else or nothing at all? So it's freeing oneself not only from the internal pressure of thinking, as a doctor, I have to get the right answer, but also the external pressure that allows you to think, you know what, if I build trust with this person by listening to them, both they and I can let go of the defensive side and allow something more creative to happen.
SPEAKER_00Yeah. Um it it makes sense. I suppose that's it establishing a relationship in that way with that patient and and um establishing trust so that they're able to explore swimming in that ocean of uncertainty, I suppose, with you. Um how does one I mean this is part of your educator role now, but how does one do that in in um of 10 minutes in general practice, or or um, you know, if you're an AE in in the side in behind a curtain in um how does one do that?
SPEAKER_01Okay, I I I don't think I have run a single training session in more than two decades where somebody hasn't asked that question. And I suppose I've developed a fairly standard answer to it, which is how much time do you think we waste by rushing? How much time do you think we waste by going down pointless rabbit holes because we haven't actually checked with the person whether the question we've asked with them is the right question, whether the topic we're focusing on is the right topic, and how much of our own time do we waste because they're gonna come back and see us because we didn't listen to the them the first time? How much of other doctors and health professionals' time are they gonna waste by going to them and saying that doctor was a complete waste of time because you know he just went, he or she just went down a kind of track that was not of my own choice and not of my own making. And I think by the judicious use of very different kinds of questions, um one can be far more efficient, even in 10 minutes, even by uh somebody's trolley in an AE department.
SPEAKER_00Okay, okay. Food for thought there, certainly. Um in terms of the um the patients who come to us, um, and some of the things that we hear so often from them um is the fear of missing something. So it is have I not as have I missed something, that means that a patient is going to come to harm and or I'm going to get into trouble. And um that uncertainty, um, though all those questions lead to a huge a great great amount of distress um in our um in the patient setting that I have seen and and and my colleagues um see and it can become pathological, they become can become quite unwell um with that over time. Um what is your experience of dealing with colleagues um before and how how do you sort of how do you how how do you kind of prevent that happening? How do you prevent people from getting to that that stage?
SPEAKER_01Okay, uh again a two-fold answer. Uh the first point of my answer is that I think there is a lot of evidence that if you ask good, open, permissive questions that allow people to tell their story, they might actually tell you more medical information than if you take them through the kind of standard clerking litany. Yeah. They will, because they're relaxed and because they trust you, it will free up their memory to say, oh, I've just thought of something quite important that they wouldn't have told you if you just grilled and interrogated them. That's the first part of it. The other thing is, of course, you have to be a safe doctor, of course you need to know the red flags, of course you need to safety net people, but it doesn't have to be the first thing you do. It doesn't have to be the, you know, the first question doesn't have to be, have you seen blood in your poo?
SPEAKER_00Yeah.
SPEAKER_01It could be, would you mind telling me a little bit about yourself? Because it's the first time we've met. And a whole load of stuff will pour out with a lot of medical facts in it. And then, of course, we, you know, when the moment is right, you can actually say almost apologetically, look, you know, I I'm glad I've learned so much about you. I do need to ask some quite precise questions from a medical point of view, just to check things out safely. Uh, have you seen any blood in your poo? Yeah, it's it's it's turning things on their head. I often teach, why not take a family and social history, so-called, or hearing somebody's story, another way of putting it, before you actually dive into the medical details. Paradoxically, it might make you a better clinical doctor.
SPEAKER_00It's a really nice question. It's not really nice opener, actually, because um I think it comes back to what you were talking about earlier in um defensive medicine almost. I think people now it's so the consultation has almost been turned on its head. So you start with get the red flags out of the way first. You know, um, is this is this cancer? Is this something life-threatening? And then you move. If you've got time, you might touch on actually the person, person behind the symptoms. Um, so yeah, I mean, having opening a consultation with can you tell me a little bit about yourself? Um, I think that that I yeah, that doesn't happen very often nowadays, I don't, I don't think, sadly. Um and and it reminds me of after doing some working occupational health, actually, one of the things I always do in in in general practice is ask what people do in life um generally in the consultation, and that takes them by surprise, I find. Oh, yeah. So it's really refreshing actually that that that that um but I I suspect that people don't do that because they're worried it's going to take too long to get through the rest of the consultation.
SPEAKER_01My own experience and the experience of I think the big majority of people that I've worked with and taught is that actually the opposite is true. Uh people take convincing, uh people sometimes report that it makes things longer before it makes things shorter, but that it does over time make things shorter because you learn a particular kind of curiosity and a particular kind of focus that that picks up cues that you might otherwise have missed. The really sad thing is GPs who treat everything as if it's peritonitis or potentially peritonitis, whereas they probably see a real case of peritonitis, what, maybe once every two or three years.
SPEAKER_00Yeah. Yeah. I think that's the um, I think that that's the sort of uh route that that almost training and modern medicine has sent us down is this sort of, yeah, as I said, try make sure the red flags are not there first, and then and then you can sort of relax a little bit and and um and uh learn a bit more about the person who's come to see you, yeah. Um which is a shame really. Um and I I do wonder if um if uh that will if we'll manage to claw that back.
SPEAKER_01Um well I sorry to interrupt, Zed. I think that the loss of continuity in many places has made a big difference, yeah, but I don't think we should blame everything on the loss of continuity because it's possible to see somebody for the first time and still forge a relationship with them. You can say, look, I'm a I'm a locum, I only happen to be here today, but I'm still interested to know a bit about you know who's at home, who's who's your household. It sort of may help me understand this. And a typical family therapy question of, you know, who who who is the most worried about it? Did you come here under your own sort of motivation, or was there somebody at home who was particularly worried about it? I mean, these are such basic questions in the context of systemic family therapy. Um, and and it's extraordinary how how many GPs don't even know about them or rarely use them.
SPEAKER_00Yeah. Tell us a bit more about them as as you hear.
SPEAKER_01More about those kind of questions.
SPEAKER_00Yes, yeah, very interesting. Because it's not I don't not many places um uh talk about this actually, really, in the terms of a consultation.
SPEAKER_01Um well, they're they're almost infinite because once you start asking people questions about context, you move away from content and you move towards context, you know, you ask questions like the one you've said, which is, you know, what what what do you do for a living? You ask questions like who's at home, you know, who's around in the family and is most worried about this, you know, and typical questions like, you know, if if if so and so was in the room, what would they say that they were most worried about or you were most worried about, and and so on. I mean, that we don't teach them by rote, we just teach the stance that invites people to ask these questions because against all their expectations, context questions reveal very important content, both from an emotional social point of view, but also from a strictly clinical medical point of view.
SPEAKER_00And my sense is that it just makes the consultation altogether more interesting, actually, um, hearing here hearing the answers to questions like that. Um, as the people stop being symptoms of medical tech medical textbook and um and yeah, gonna come alive almost. I don't know if that makes sense.
SPEAKER_01Yes, and you get feedback very often, like um I I I think this is the first time for a long time that I felt listened to. Yes. Um or uh, you know, all kinds of reactions. I mean, you know, can I can I see you again? Yeah, can I uh are you are you here? Are you are you here regularly? You know, are you going to be around? Can I book can I book another appointment with you? And just very human reactions. Um, I've never been asked these questions before. That's a very interesting question. It's funny you should ask me that. You know, what you've asked me has just made me remember something, and something's just popped into my mind. I mean, these are much, much more like normal social conversations. And the fact that they're more like social conversations actually means they're medically more effective as well. You know, our example, I often quote, you know, somebody goes to see their doctor and says their feet are getting bigger. And the next question is, have you noticed any change with your vision? Because the doctor's thinking about acromegaly and growth hormone and pituitary tumours, and the patient is sitting there thinking, you know, what what planet, what planet are they on? Why this question? There's no signposting, there's no, you know, explanation of our own belief systems. So we can't we for we're on another planet. And I I sometimes describe what I what I well, a friend of mine described what I do as uh remedial therapy for selective brain damage, because we are so in it's so inculcated us that we need to think and speak in a certain way that we forget how incredibly abnormal it is by the standards of normal social conversations.
SPEAKER_00Yeah, yeah, yes, that's right. Um, yeah, very interesting. Um moving to um reassurance. And um uh again, what we what we find with um the patients that we see is that um checking, uh people start to check and they start to check once and it and then it you know twice, and then before you know it, they've you've added another hour, two hours to a day because you can't leave for the for the fear of missing missing something and you need to check it. Um what's your Take on checking and your experience of dealing with colleagues who start to develop that as a coping mechanism?
SPEAKER_01Yes. I think each case is individual and different, and I think you need to find exactly why that person and how they have disappeared spiraled down that particular trajectory. And it may be that their initial training, I mean, let's assume they're GPs, although obviously that's not always the case, but it may be that their training was with somebody who was a bit obsessive in that way, uh, or who didn't spot that they needed some remedial work around their anxiety about uncertainty. It might be that they work in a context where people do police them excessively. Uh, it may be that they have had specific incidents that have triggered that. I mean, complaints, obviously, medical mistakes, obviously. I mean, I'm I'm telling you your own job's aid. I mean, you must come across this all the time, but I think you need to do uh uh you need to do a needs assessment, really. What has got them into this pickle and what are the best ways of helping them out of it?
SPEAKER_00Yeah, yeah, it is so um it is so individual, and I I'm not um uh uh putting everyone in the same in the same glove, but everyone's circumstances are indeed different. And um again, we see people who are um triggered, I suppose, is a word by by memories of a complaint or an inquest or a or a person or a personal injury claim or something which has um or they've heard heard of a colleague, that's very, very common. Um the the medical media um will be full of cases that where where um where things have gone wrong um and word gets around and you start before you know it you start to second guess, second guess yourself. So that that's really very common. Um, I think in it really is a fear. Fear, I think, of causing harm and getting people getting into trouble. Um that's at the root of quite a lot of what we see.
SPEAKER_01Yes. Um I I I think uh uh it's it's really important to accept you you can't get through um uh a medical career without making mistakes. Um there was a wonderful book published actually by the by the GMC a few years ago where very eminent doctors described some of the mistakes they'd made. You can't get through a medical career without having complaints, some of which will be justified, some of which, in your view, will not be unjustified, and the uh outcome of those cases may be uh uh, you know, a bit like Russian roulette, really. Uh it may in your mind have no connection with your own culpability or otherwise. And I think we need just need to uh yeah, just just need to nurture people in the belief that this will happen and it doesn't go to the core of their identities. Doesn't mean they're a bad person, certainly doesn't mean they're a bad doctor.
SPEAKER_00Great, thank you. Um, and just touching on um burnout, um, again, burnout is a word that has really uh featured highly, I suppose, in in um in the service in in patients who register with us, talk talk about coming to us feeling burnt out. And I wondered how much of burnout can be attributed or associated with um the intolerance of of managing uncertainty in in the course of one's work. And I wondered if you had any reflections on on that in your own, in your experience of again as an educator therapist GP again.
SPEAKER_01I think burnout is multifactorial, and in my own experience, uh the most important factor is often uh a lack of support in the team, a lack of supervision. And I use supervision with a small S. I don't mean you have to engage with a formal paid supervisor, but just having a climate around in your workplace in which you are um you're regularly asked about how you're doing, you're regularly asked to discuss cases or invited to discuss cases that are bugging you or causing you difficulty. Um I yeah, I just just to be supported. One of one of the very first books I edited was actually way back in 2000 and um 2003, it was, and it was called Supervision and Support in Primary Care. And it was the first book actually to say that nobody in primary care, least of all the GPs, should be working without systems of supervision and support around them, which could be anything. It could be going to a barley group, it could just be working with a very sympathetic colleague in the next room where you didn't feel anxious about going and knocking on their door.
SPEAKER_00Yeah, yeah, yeah, yeah. And that's um hugely, just hugely helpful. Because again, uh and I know we're talking about primary care here, but I suppose all aspects of medicine can can feel very, really quite isolating. And um, I've certainly worked in GP surgeries where I've gone from morning till evening without seeing anyone but the without except the patient. I think having that support system in place, whether it's a supportive colleague or access to a violent group, as you say, or some reflective practice group of some kind like is in invaluable, which brings me nicely actually onto reflective practice. And you kind of uh touched on this and uh cover this uh uh um a little bit just now, but what is the role of reflective practice in helping people um I use the word manage uncertainty, but you perhaps you can maybe you've got a better word for it.
SPEAKER_01Uh no, I don't think I have uh can improve on that really. I think um I uh always draw people's attention to the fact that reflection literally means looking in a mirror. So uh one level of reflection is being able to look at yourself in the mirror. Um, and uh often it doesn't, it's not visual, it's more kind of it's an inner dialogue. I talk a lot about inner dialogue and the importance of cultivating one's inner dialogue, actually having time before a consultation to look at the notes, even if it shortens the consultation and to form some hypotheses about what this consultation might be about, to stop and reflect on it afterwards. And then and then the the next level of reflection is actually just simply saying to somebody else, could can I talk this through with you? I just had a consultation and the patient said something rather strange and it's bugging me. Um, or I've just heard from a receptionist that um somebody I thought really liked me had said they'll they'll they'd want to see anybody except Dr. Lorna. And I don't really understand it, and I'm not sure if I can approach them or if I can try and find out what I may have done wrong. You know, I just like to talk that through before it before it it overwhelms me. And it's the lack of talking to yourself and it's the lack of talking to others um that that that is a is a tremendous stressor and a factor for burnout.
SPEAKER_00Yeah, yeah, but yeah, totally. And it's what we see. Uh those who work in supportive teams, um, yeah, it it I think it's so protective, um, so protective um of um of one's well-being. So yeah, it totally makes sense. Um and I think correct me if I'm wrong, but I think you have talked in the past about actually coming to a point where you can actually enjoy uncertainty. Is that something is is that is that correct?
SPEAKER_01I I think that the the the um the the core of uh uh the approach that I teach and my colleagues teach is it puts that at its center, which is really to to celebrate the fact that I I don't know where this conversation is going. Um I you know, you and I didn't know at the beginning of this conversation where we would be going, and here we are, and it's been at least to my end, fascinating and enjoyable. And um, I think the same is true of consultations. It's it's classic that somebody comes in and says, uh, you know, I I've got I've got four problems. And and the classic GP response is, oh my god, how are we going to get through those? And the curious response is that's jolly interesting. Are are they connected? Is is there a fifth problem? You know, sometimes there is. Classic case where there was, and we never got around to the four problems because I just asked, is there a fifth problem? And um it's that idea that uh an art uh I wrote an article in the BMJ recently called the pluripotent consultation, which is the consultation has the capacity go to go in almost infinite number of directions. There will never be, well, there occasionally be, if it's peritonitis, there will be a single direction. There will be if it's a bunion, but but so many consultations are not like that. They're pluripotent, and one can really celebrate and enjoy the number of places they could go and have patients saying, I never expected to get here. It wasn't what I thought I'd come about, but you know, here we are.
SPEAKER_00Yeah, yeah. Okay. So I guess that's almost um it's maintaining curiosity as to where the journey takes you, I think, isn't it? Okay. Um, and um I think Alice is always keen on um on tools on how to manage manage different aspects of of um life in in the profession. Um so I mean I I won't take too much more of your time, but if you were talking to yourself as a newly trained GP or therapist even, what would you say to yourself in relation to dealing with uncertainty?
SPEAKER_01I'm not sure I'd call them tools, but I think um I I I one one question is um what what what does this person think I need to know to to get them, to understand them? They might even ask that question, you know, what what what what are the most important things I need to know about you to kind of get a sense of who you are? Um is there is there anything important I need to know about you that I haven't asked? We ask the questions we choose to ask. We never ask them what questions people would like us to ask them or what questions we haven't asked that we wish they had, wish they wish we had. So it's that kind of uh drawing back the lens, widening the whole field and thinking, what am I missing? Um have I have I made any assumptions about you that you think have got in the way of me understanding what what you want? Yeah kind of thing.
SPEAKER_00Yeah. Thank you. That makes sense. And it uh reminds me of I think um an article you wrote, I think it was one in one of the books you write um about um it might have been you actually, but it was about a consultation where the the person consulting read that their agenda, what it is, what it what it is that they were seeking from the the the doctor, and it was a it was a an x-ray or it was some sort of and that that was really what they had come to come about. But the you wouldn't necessarily think to ask ask what it is what is it you're seeking reassurance about? What is it that you are you need? What are you needing from this? Um from me, and and it was clear that that was the outcome, that was really the that was what was being sought. Um so yeah, thank you for that. Um and I suppose again, um uh would there be sort of any any um final gems that you'd like to impart to the listeners about uncertainty and your your experience of writing about it, teaching about it? Is there a single takeaway that you'd like to leave the listeners with?
SPEAKER_01Um I can't uh out of the blue magically draw a single for it. Um, but but what comes to mind is again and again returning to uh you know uh saying at the beginning, what are you hoping to get out of this conversation? And at the end, um is there anything you were hoping to get out of this conversation that you haven't got? Just checking that this this is a conversation. Reality is reality is defined by conversations, created by conversations, and you need to be reflexive about the conversation itself. How is this going? How is this conversation going for you? Am I getting it right? And they may say I don't like being asked damn full questions like that, and that that's fine too. You say, okay, do you want me to stop asking questions and behave like a conventional doctor? Because I can do that too.
SPEAKER_00Yeah, yeah, yeah. Okay, well that that's great. Well, um thank you, John, for taking the time to talk um talk to me about uncertainty today. I hope um I hope uh I um asked all the questions that um you had hoped that I would ask. And there was not there's nothing missing. Um but uh yeah, I really appreciate you taking the time to come and talk to us about this because it's such a it's such an area um where where um that people come to us seeking help with. And um I think it's really nice to to have a I suppose an expert in the subject um to come and talk to us about it. Um so thank you very much, John. Um yeah, it's been a pleasure. Um and um what we will also do is in the um in the accompanying text, uh we'll put a couple of links to some of your most recent articles for the listeners to have a look at as well. Uh, because it's all related. But uh thanks again, John, and take care. And thank you for listening. Um, and see you soon.