The nature of medical evidence and its inherent uncertainty for the cl
http://www.100md.com
《英国医生杂志》
1 Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL, 2 Centre for Social and Policy Research, University of Teesside, Middlesbrough TS1 3BA, 3 Institute for Society, Health and Ethics, University of Cardiff, Cardiff CF10 3AT
Correspondence to: F Griffiths f.e.griffiths@warwick.ac.uk
We examined consultations with health professionals in both primary and secondary care where there was discussion of one or more of the interventions of hormone replacement therapy, bone densitometry, or breast screening. Our study included healthcare sites in contrasting socioeconomic contexts in the Midlands and north east England. The collection of these data was part of a larger study, reported elsewhere.14 15
All women aged 45-64 attending one of seven general practices or three specialist clinics in the UK NHS were invited to participate in our study. After consent was obtained, the healthcare professional audiotaped the consultations. These were reviewed for their relevance to our study. We discarded those with no mention of the relevant interventions, and we retained all the others regardless of the extent of the discussion of the interventions. Table 1 lists the details of the clinics and surgeries and consultations recorded. The details of the research process, including analysis, are on bmj.com.
Table 1 Number of consultations recorded between health professionals and women at midlife in which hormone replacement therapy, bone densitometry, or breast screening was mentioned
Overall, 109 consultations were relevant: 73 from general practice and 36 from specialist clinics. Most women attending the clinics agreed to be recorded, whereas in general practice the consent rate was lower (20% in some practices).
A key emergent theme was uncertainty and how it is discussed between health professionals and women, particularly the uncertainty inherent in medical evidence when it is applied to particular patients. The data included 64 consultations with only a brief mention of the interventions. For example, a woman discusses with the practice nurse those symptoms she thinks are due to the menopause, and hormone replacement therapy is mentioned only briefly (also see bmj.com). Owing to insufficient data, we did not include these consultations in subsequent analysis. Through a process of discussion and comparison of data, we developed categories for how uncertainty was dealt with in the remaining 45 consultations, which were recorded by 25 different health professionals (nine had more than one consultation in this dataset and of these, three had more than two). The categories were developed as a tool for understanding and reflecting on what was taking place in the consultations. The results of the analysis were presented to three university based focus groups—two of doctors and one of patients—which provided feedback on the validity of the categories from their own experience. In further comparative analysis we explored links between how uncertainty was dealt with and the healthcare issues and context.
Results
To achieve good communication between health professionals and patients, health professionals need strategies for coping with the dilemma of applying medical evidence to individual patients. These strategies could include using provisional decisions that allow for changing priorities and circumstances over time, avoiding slippage into general reassurance from a particular test result, and avoiding the creation of a myth of certainty.
Box 4: Acknowledging the inherent uncertainty of the medical evidence and negotiating a provisional decision
Extract 1: Woman is concerned about taking hormone replacement therapy
Patient: I've been having 'em, HRT patches and in the middle of the year there was a new finding.
Doctor: Right, the scare.
Patient: Right, so when they've finished I thought, I'd try to do without them.
Doctor: Right.
Patient: And I've been considering it and considering it—what I want to know is do you think—what's your opinion on it—when we talked about—when we talked about it earlier we weighed up all the pros and cons.
Doctor: Yes. Yes.
Patient: Is there a history of cancer, is there a history of heart problems—no history of cancer—but a history of heart problems so we decided it offered some a sort of protection to—but it seems to have taken a change—and then when I sort of thought about it later the percentage is quite small really isn't it.
Doctor: Yes.
Patient: When we, sort out how many people we're talking about it isn't large so I think that, I think that I'll go ahead with some more. Is that what, is that what you would advise, do you think it isn't—it isn't a big risk.
Doctor: No. It's certainly not a big risk—how long were you been on HRT for?
Patient: Oh not long—less than a year.
Doctor: OK, that's important because there's also risks associated with time that you're on HRT, so basically the longer you're on, the risk goes up, particularly if you're looking at breast cancer, but having said that you're absolutely right, the risk is still very small so any risk that there is only affects a very tiny minority of women and of course it's very difficult to know whether if something happens to you whether it's this or more likely whether it would have happened anyway.
Patient: And I was thinking of the quality of my life as well—my young lad I really need a bit more energy.
Doctor: Well that's important too (laughing).
(The discussion continues and blood pressure is checked. Towards the end of the consultation the doctor says:)
So I'll just give you some more now—and then what we do...if you're happy with them you can either come and see one of us or see (practice nurse) in six months for the next lot. (General practice, consultation 072)
Extract 2: Consultation to review hormone replacement therapy
Patient: Err my Estraderm patches, I'm getting a new prescription today, now the last time I saw the nurse, she said this would be my last prescription and I wouldn't be able to have any more.
Doctor: Did she mean because...
Patient: Because of my age or something—and I thought well I'll come and see you, because I did funnily enough try to come off patches myself, and I still got very flushed, so I thought I better just pop in and see you while I'm here anyway.
Doctor: Yes, I mean you're 62 and therefore, sort of 10 years beyond a natural menopause but you had a pretty dramatic menopause—you've had your ovaries taken out.
Patient: Oh I've had all sorts.
Doctor: I guess, she may have been thinking in terms of osteoporosis prevention, in that 10 years would be adequate for that and also as you also will know, a longer term use of HRT is associated with breast cancer, however, if you feel that you'd rather carry on, bearing in mind you know the increased risk of breast cancer.
Patient: Yes.
Doctor: You know the big one, then I don't have any particular problem with this.
Patient: What about after this six months I mean obviously it's—would it—if I only say tried one a week instead of two how would that—or don't you do that with HRT.
Doctor: Well, or else what you could well. I'm just looking to see if they come in 25s—if you put one a week on, you'd be fine for the first half of the week and then...
Patient: Sure enough.
Doctor: Yes, they come in 25s so one option might be to draw three months of the 25s to see how you get on.
Patient: Yes, yes.
Doctor: You might find that when you decide to stop you have no hot flushes or you know whatever you got when you last decided to stop.
But I think she probably just felt that that she would flag it up about breast cancer. (General practice, consultation 002)
Extract 3: Consultation with practice nurse
The woman and nurse have discussed the increase in breast cancer risk from taking hormone replacement therapy long term as shown by the US study reported in the media. The woman is feeling well while receiving hormone replacement therapy.
Nurse: But there is still a risk of breast cancer—but there again there is a risk of breast cancer in this age group anyway, but it is increased with long term use of...
Patient: Well when you say long term use of...
Nurse: Long term—10 years plus.
Patient: Oh, I'm getting up to that one now aren't I—8 years isn't it?
Nurse: Yes, that's right—they advise five years, fine, up to 10 years is okay and then to rethink about it.
Patient: Well I mean by then I might be okay we'll just have to wait and see.
Nurse: That's right—blood pressure's fine—but it is something that you've got to be aware of.
Patient: Oh yes, I realise that—yes. (General practice, consultation 083)
We studied how health professionals and women have been dealing with the dilemma of uncertainty inherent in medical evidence in relation to medical interventions focused on women at midlife. These interventions offer prevention, screening, and relief of symptoms, so the results may inform other areas of medicine where the type of evidence base is similar, such as prevention and treatment of chronic diseases. Further research may be needed to examine consultations about acute illness. The recorded consultations include examples where the doctor was attempting to communicate risk in ways that are known to be unhelpful to patients,16 particularly when weaving a coherent story of certainty. Training in clinical communication, including how to communicate risk, is important. Many successful models exist for such training. Our research does not suggest a new model, but highlights the importance of including in existing models an awareness of the dilemma involved in applying medical evidence to individual patients and strategies to cope with this.
The health professionals expressed an understanding of the evidence about the risks and benefits of the interventions more or less in line with the prevailing medical consensus at the time. During data collection, however, new evidence on the risks of hormone replacement therapy was published,3 so the content of some of the consultations would be different with less positive accounts of hormone replacement therapy.17 However, it is the way the accounts of the medical evidence were interwoven that produces the impression of certainty rather than the detail.
The data reveal a danger of creating a myth of certainty around what is inherently uncertain through the way the medical evidence is presented and discussed. This seems to be particularly so when there is a test result, such as for bone densitometry, or where an intervention such as hormone replacement therapy is being initiated. This way of presenting evidence about a medical intervention reinforces the idea of medicine as a precise science independent of context and people with the ability to predict outcome, which has become incorporated into lay models of illness.18 Apparent certainty can be persuasive and can lead to health professionals changing their understanding of the evidence to fit the story they are presenting to the patient. Part of learning to communicate well about risks and benefits of health interventions, and so truly to include patients in decision making, may be to fully recognise the uncertainties inherent in clinical evidence and not to hide this from patients. Health professionals would then stop reinforcing the myth of medicine as a science of certainty and prediction and could work creatively with its uncertainties alongside patients.
In consultations where hormone replacement therapy was being reviewed or restarted, a provisional decision was often agreed. This avoided the danger of further reinforcing the myth of certainty. The women interpreted the medical evidence for their current situation,19 including their physical symptoms, hopes and fears, social situation, and priorities.14 They may have been more able to do this at a review appointment as by then they had some experience of hormone replacement therapy. They may also have sought information themselves about the medical evidence, and through this process developed their ability to assess the evidence.20
Time is an important dimension in this analysis. The clinicians in the breast clinic struggled to stay with the here and now in their desire to reassure the women. Consultations at the bone clinic and hormone replacement therapy clinic included mention of review of treatment in three, four, or five years. Mention of this time added to the impression of certainty rather than implying something provisional. The use of time, by making provisional plans, was the striking feature of the category of acknowledging the uncertainty. This fits in with reality for women, as their context, experience, and level of risk changes over time. The consultations in this category may provide useful examples of using time in health related decisions for use in the teaching of communication skills, as they show how a conditional decision can be reached and be a satisfactory outcome for a consultation.
Reassurance is appropriate where there are high levels of anxiety, such as in breast clinics (see box 2, extract 1); however, it is also possible to be clear about the temporary and tissue specific nature of the test result. Patients may seek certainty from health professionals because they feel vulnerable at that time or because they believe the myth of medical certainty. Health professionals are in a position of influence with patients, so in responding to a desire for certainty they should critically reflect on the effect this may have on their patient now and in the future, such as building an expectation of certainty of outcome from medical interventions. The assessment of how much to emphasise certainty or not for each patient should be explicit in the training of medical communication skills.
What is already known on this topic
Uncertainty about outcome for an individual patient is intrinsic to the nature of medical evidence
This creates a dilemma that will always be present
Communicating evidence to patients is a key part of clinical consultations, with a growing evidence base of how it is best achieved
What this study adds
A dilemma for health professionals is creating a myth of certainty around what is inherently uncertain
This may be avoided by negotiating provisional decisions
In the consultations where a provisional decision was made, negotiation was present between the health professional and woman. How much it was guided by the woman and how much by the health professional varied (see box 4). Data from the study shows that women vary in their preference for involvement in decision making with health professionals, and that this varies according to their circumstances.15 It is the provisional nature of the decision, rather than the woman's involvement in the decision, that seems to allow the decision to sit comfortably with acknowledging the uncertainty inherent in medical evidence.
In general practice in the United Kingdom, it is possible to make provisional decisions with patients and to review them. It provides continuity of care for individuals,21 of which this decision making process is one aspect. In contrast, specialists may see patients only once or review their treatment only at infrequent intervals making it more difficult to negotiate provisional decisions. The challenge for health professionals is to develop the skills to acknowledge uncertainty and to negotiate provisional decisions, including when considering test results or starting new interventions.
The major types of evidence used in clinical medicine cannot be directly applied to an individual, so health professionals will continue to face the dilemma this creates. Through the teaching of training in communication skills and the design of healthcare systems it is important to enable health professionals to make provisional decisions with individual patients. This approach to decision making has the most potential for a continuing acknowledgment of the inherent uncertainty in medical evidence, an uncertainty which will remain even with progress in basing medical interventions on robust research evidence.
Details of the research process are on bmj.com
We thank the participants for their time, the Leicester Warwick Medical School GP Lecturer Group, the University of Warwick Academic GP Registrar Group, the University of Warwick Primary Care Research User Group for their contribution to the study, and the reviewers for their suggestions.
Contributors: FG was principal investigator for the study. EG was coapplicant on the study funding proposal, managed a study field site, and contributed to each stage of the study development, process, analysis, and reporting. Gillian Bendelow and Kathryn Backett Milburn were coapplicants on the study funding proposal, contributed to the design of the study, advised on the conduct of the study, and contributed to analysis and reporting. Di Thompson and MT undertook the data collection and contributed to analysis and reporting. Pamela Lowe and Antje Lindenmeyer contributed to analysis.
Funding: Economic and Social Research Council project grant (L218252038); part of the innovative health technology programme.
Competing interests: None declared.
Ethical approval: Warwickshire local research ethics committee and Hartle-pool and North Tees local research ethics committee.
References
Fox RC. Medical uncertainty revisited. In: Bendelow G, Carpenter M, Vautier C, Williams S, eds. Gender, health and healing: the public/private divide. London: Routledge, 2002: 236-53.
Willis J. The paradox of progress. Oxford: Radcliffe Medical Press, 1995.
Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002;288: 321-33.
Rosenberger NR. The process of discourse: usages of a Japanese medical term. Soc Sci Med 1992;34: 237-47.
McWhinney IR. An acquaintance with particulars... Fam Med 1989;21: 296-8.
Gorovitz S, MacIntyre A. Toward a theory of medical fallibility. J Med Philos 1976;1: 51-71.
Beresford E. Uncertainty and the shaping of medical decisions. Hastings Cent Rep 1991;21: 6-11.
Tanenbaum S. What physicians know. N Engl J Med 1993;329: 1268-71.
Tanenbaum S. Evidence and expertise: the challenge of the outcomes movement to medical professionalism. Acad Med 1999;74: 757-63.
Tanenbaum SJ. Knowing and acting in medical practice: the epistemological politics of outcomes research. J Health Polit, Policy Law 1994;19: 27-44.
Haynes RB, Devereaux PJ, Guyatt GH. Physicians' and patients' choices in evidence based practice. BMJ 2002;324: 1350.
Summerskill WS, Pope C. "I saw the panic rise in her eyes and evidence-based medicine went out of the door." An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease. Fam Pract 2002;19: 605-8.
Lewis D, Robinson J, Wilkinson E. Factors involved in deciding to start preventive treatment: qualitative study of clinicians' and lay people's attitudes. BMJ 2003;327: 841-7.
Green E, Thompson D, Griffiths FE. Narratives of risk: women at midlife, medical "experts" and health technologies. Health Risk Soc 2002;4: 243-86.
Griffiths FE, Green EE, Bendelow G, Backett-Milburn K. Innovative health technologies at women's midlife; theory and diversity among women and experts. Swindon: Economic and Social Research Council, 2003.
Edwards A, Elwyn G, Mulley A. Explaining risks: turning numerical data into meaningful pictures. BMJ 2002;324: 827-30.
Minelli CAK, Sutton A, Cooper N. Benefits and harms associated with hormone replacement therapy: clinical decision analysis. BMJ 2004; 328.
Griffiths F, Green E. A normal biological process? Brittle bones, HRT and the patient-doctor encounter. In: Williams SJ, Birke L, Bendelow GA, eds. Debating biology: sociological reflections on health medicine and society. London: Routledge, 2003: 210-22.
Massé R, Légaré F. The limitations of a negotiation model for perimenopausal women. Soc Health Illness 2001;23: 44-64.
Bond M, Bywaters P. Working it out for ourselves: women learning about hormone replacement therapy. Womens Stud Int Forum 1998;21: 65-76.
WONCA Europe. The European definition of general practice/family medicine, 2002. www.euract.org/pap041.html (accessed 12 Jul 2004).(Frances Griffiths, senior clinical lectu)
Correspondence to: F Griffiths f.e.griffiths@warwick.ac.uk
We examined consultations with health professionals in both primary and secondary care where there was discussion of one or more of the interventions of hormone replacement therapy, bone densitometry, or breast screening. Our study included healthcare sites in contrasting socioeconomic contexts in the Midlands and north east England. The collection of these data was part of a larger study, reported elsewhere.14 15
All women aged 45-64 attending one of seven general practices or three specialist clinics in the UK NHS were invited to participate in our study. After consent was obtained, the healthcare professional audiotaped the consultations. These were reviewed for their relevance to our study. We discarded those with no mention of the relevant interventions, and we retained all the others regardless of the extent of the discussion of the interventions. Table 1 lists the details of the clinics and surgeries and consultations recorded. The details of the research process, including analysis, are on bmj.com.
Table 1 Number of consultations recorded between health professionals and women at midlife in which hormone replacement therapy, bone densitometry, or breast screening was mentioned
Overall, 109 consultations were relevant: 73 from general practice and 36 from specialist clinics. Most women attending the clinics agreed to be recorded, whereas in general practice the consent rate was lower (20% in some practices).
A key emergent theme was uncertainty and how it is discussed between health professionals and women, particularly the uncertainty inherent in medical evidence when it is applied to particular patients. The data included 64 consultations with only a brief mention of the interventions. For example, a woman discusses with the practice nurse those symptoms she thinks are due to the menopause, and hormone replacement therapy is mentioned only briefly (also see bmj.com). Owing to insufficient data, we did not include these consultations in subsequent analysis. Through a process of discussion and comparison of data, we developed categories for how uncertainty was dealt with in the remaining 45 consultations, which were recorded by 25 different health professionals (nine had more than one consultation in this dataset and of these, three had more than two). The categories were developed as a tool for understanding and reflecting on what was taking place in the consultations. The results of the analysis were presented to three university based focus groups—two of doctors and one of patients—which provided feedback on the validity of the categories from their own experience. In further comparative analysis we explored links between how uncertainty was dealt with and the healthcare issues and context.
Results
To achieve good communication between health professionals and patients, health professionals need strategies for coping with the dilemma of applying medical evidence to individual patients. These strategies could include using provisional decisions that allow for changing priorities and circumstances over time, avoiding slippage into general reassurance from a particular test result, and avoiding the creation of a myth of certainty.
Box 4: Acknowledging the inherent uncertainty of the medical evidence and negotiating a provisional decision
Extract 1: Woman is concerned about taking hormone replacement therapy
Patient: I've been having 'em, HRT patches and in the middle of the year there was a new finding.
Doctor: Right, the scare.
Patient: Right, so when they've finished I thought, I'd try to do without them.
Doctor: Right.
Patient: And I've been considering it and considering it—what I want to know is do you think—what's your opinion on it—when we talked about—when we talked about it earlier we weighed up all the pros and cons.
Doctor: Yes. Yes.
Patient: Is there a history of cancer, is there a history of heart problems—no history of cancer—but a history of heart problems so we decided it offered some a sort of protection to—but it seems to have taken a change—and then when I sort of thought about it later the percentage is quite small really isn't it.
Doctor: Yes.
Patient: When we, sort out how many people we're talking about it isn't large so I think that, I think that I'll go ahead with some more. Is that what, is that what you would advise, do you think it isn't—it isn't a big risk.
Doctor: No. It's certainly not a big risk—how long were you been on HRT for?
Patient: Oh not long—less than a year.
Doctor: OK, that's important because there's also risks associated with time that you're on HRT, so basically the longer you're on, the risk goes up, particularly if you're looking at breast cancer, but having said that you're absolutely right, the risk is still very small so any risk that there is only affects a very tiny minority of women and of course it's very difficult to know whether if something happens to you whether it's this or more likely whether it would have happened anyway.
Patient: And I was thinking of the quality of my life as well—my young lad I really need a bit more energy.
Doctor: Well that's important too (laughing).
(The discussion continues and blood pressure is checked. Towards the end of the consultation the doctor says:)
So I'll just give you some more now—and then what we do...if you're happy with them you can either come and see one of us or see (practice nurse) in six months for the next lot. (General practice, consultation 072)
Extract 2: Consultation to review hormone replacement therapy
Patient: Err my Estraderm patches, I'm getting a new prescription today, now the last time I saw the nurse, she said this would be my last prescription and I wouldn't be able to have any more.
Doctor: Did she mean because...
Patient: Because of my age or something—and I thought well I'll come and see you, because I did funnily enough try to come off patches myself, and I still got very flushed, so I thought I better just pop in and see you while I'm here anyway.
Doctor: Yes, I mean you're 62 and therefore, sort of 10 years beyond a natural menopause but you had a pretty dramatic menopause—you've had your ovaries taken out.
Patient: Oh I've had all sorts.
Doctor: I guess, she may have been thinking in terms of osteoporosis prevention, in that 10 years would be adequate for that and also as you also will know, a longer term use of HRT is associated with breast cancer, however, if you feel that you'd rather carry on, bearing in mind you know the increased risk of breast cancer.
Patient: Yes.
Doctor: You know the big one, then I don't have any particular problem with this.
Patient: What about after this six months I mean obviously it's—would it—if I only say tried one a week instead of two how would that—or don't you do that with HRT.
Doctor: Well, or else what you could well. I'm just looking to see if they come in 25s—if you put one a week on, you'd be fine for the first half of the week and then...
Patient: Sure enough.
Doctor: Yes, they come in 25s so one option might be to draw three months of the 25s to see how you get on.
Patient: Yes, yes.
Doctor: You might find that when you decide to stop you have no hot flushes or you know whatever you got when you last decided to stop.
But I think she probably just felt that that she would flag it up about breast cancer. (General practice, consultation 002)
Extract 3: Consultation with practice nurse
The woman and nurse have discussed the increase in breast cancer risk from taking hormone replacement therapy long term as shown by the US study reported in the media. The woman is feeling well while receiving hormone replacement therapy.
Nurse: But there is still a risk of breast cancer—but there again there is a risk of breast cancer in this age group anyway, but it is increased with long term use of...
Patient: Well when you say long term use of...
Nurse: Long term—10 years plus.
Patient: Oh, I'm getting up to that one now aren't I—8 years isn't it?
Nurse: Yes, that's right—they advise five years, fine, up to 10 years is okay and then to rethink about it.
Patient: Well I mean by then I might be okay we'll just have to wait and see.
Nurse: That's right—blood pressure's fine—but it is something that you've got to be aware of.
Patient: Oh yes, I realise that—yes. (General practice, consultation 083)
We studied how health professionals and women have been dealing with the dilemma of uncertainty inherent in medical evidence in relation to medical interventions focused on women at midlife. These interventions offer prevention, screening, and relief of symptoms, so the results may inform other areas of medicine where the type of evidence base is similar, such as prevention and treatment of chronic diseases. Further research may be needed to examine consultations about acute illness. The recorded consultations include examples where the doctor was attempting to communicate risk in ways that are known to be unhelpful to patients,16 particularly when weaving a coherent story of certainty. Training in clinical communication, including how to communicate risk, is important. Many successful models exist for such training. Our research does not suggest a new model, but highlights the importance of including in existing models an awareness of the dilemma involved in applying medical evidence to individual patients and strategies to cope with this.
The health professionals expressed an understanding of the evidence about the risks and benefits of the interventions more or less in line with the prevailing medical consensus at the time. During data collection, however, new evidence on the risks of hormone replacement therapy was published,3 so the content of some of the consultations would be different with less positive accounts of hormone replacement therapy.17 However, it is the way the accounts of the medical evidence were interwoven that produces the impression of certainty rather than the detail.
The data reveal a danger of creating a myth of certainty around what is inherently uncertain through the way the medical evidence is presented and discussed. This seems to be particularly so when there is a test result, such as for bone densitometry, or where an intervention such as hormone replacement therapy is being initiated. This way of presenting evidence about a medical intervention reinforces the idea of medicine as a precise science independent of context and people with the ability to predict outcome, which has become incorporated into lay models of illness.18 Apparent certainty can be persuasive and can lead to health professionals changing their understanding of the evidence to fit the story they are presenting to the patient. Part of learning to communicate well about risks and benefits of health interventions, and so truly to include patients in decision making, may be to fully recognise the uncertainties inherent in clinical evidence and not to hide this from patients. Health professionals would then stop reinforcing the myth of medicine as a science of certainty and prediction and could work creatively with its uncertainties alongside patients.
In consultations where hormone replacement therapy was being reviewed or restarted, a provisional decision was often agreed. This avoided the danger of further reinforcing the myth of certainty. The women interpreted the medical evidence for their current situation,19 including their physical symptoms, hopes and fears, social situation, and priorities.14 They may have been more able to do this at a review appointment as by then they had some experience of hormone replacement therapy. They may also have sought information themselves about the medical evidence, and through this process developed their ability to assess the evidence.20
Time is an important dimension in this analysis. The clinicians in the breast clinic struggled to stay with the here and now in their desire to reassure the women. Consultations at the bone clinic and hormone replacement therapy clinic included mention of review of treatment in three, four, or five years. Mention of this time added to the impression of certainty rather than implying something provisional. The use of time, by making provisional plans, was the striking feature of the category of acknowledging the uncertainty. This fits in with reality for women, as their context, experience, and level of risk changes over time. The consultations in this category may provide useful examples of using time in health related decisions for use in the teaching of communication skills, as they show how a conditional decision can be reached and be a satisfactory outcome for a consultation.
Reassurance is appropriate where there are high levels of anxiety, such as in breast clinics (see box 2, extract 1); however, it is also possible to be clear about the temporary and tissue specific nature of the test result. Patients may seek certainty from health professionals because they feel vulnerable at that time or because they believe the myth of medical certainty. Health professionals are in a position of influence with patients, so in responding to a desire for certainty they should critically reflect on the effect this may have on their patient now and in the future, such as building an expectation of certainty of outcome from medical interventions. The assessment of how much to emphasise certainty or not for each patient should be explicit in the training of medical communication skills.
What is already known on this topic
Uncertainty about outcome for an individual patient is intrinsic to the nature of medical evidence
This creates a dilemma that will always be present
Communicating evidence to patients is a key part of clinical consultations, with a growing evidence base of how it is best achieved
What this study adds
A dilemma for health professionals is creating a myth of certainty around what is inherently uncertain
This may be avoided by negotiating provisional decisions
In the consultations where a provisional decision was made, negotiation was present between the health professional and woman. How much it was guided by the woman and how much by the health professional varied (see box 4). Data from the study shows that women vary in their preference for involvement in decision making with health professionals, and that this varies according to their circumstances.15 It is the provisional nature of the decision, rather than the woman's involvement in the decision, that seems to allow the decision to sit comfortably with acknowledging the uncertainty inherent in medical evidence.
In general practice in the United Kingdom, it is possible to make provisional decisions with patients and to review them. It provides continuity of care for individuals,21 of which this decision making process is one aspect. In contrast, specialists may see patients only once or review their treatment only at infrequent intervals making it more difficult to negotiate provisional decisions. The challenge for health professionals is to develop the skills to acknowledge uncertainty and to negotiate provisional decisions, including when considering test results or starting new interventions.
The major types of evidence used in clinical medicine cannot be directly applied to an individual, so health professionals will continue to face the dilemma this creates. Through the teaching of training in communication skills and the design of healthcare systems it is important to enable health professionals to make provisional decisions with individual patients. This approach to decision making has the most potential for a continuing acknowledgment of the inherent uncertainty in medical evidence, an uncertainty which will remain even with progress in basing medical interventions on robust research evidence.
Details of the research process are on bmj.com
We thank the participants for their time, the Leicester Warwick Medical School GP Lecturer Group, the University of Warwick Academic GP Registrar Group, the University of Warwick Primary Care Research User Group for their contribution to the study, and the reviewers for their suggestions.
Contributors: FG was principal investigator for the study. EG was coapplicant on the study funding proposal, managed a study field site, and contributed to each stage of the study development, process, analysis, and reporting. Gillian Bendelow and Kathryn Backett Milburn were coapplicants on the study funding proposal, contributed to the design of the study, advised on the conduct of the study, and contributed to analysis and reporting. Di Thompson and MT undertook the data collection and contributed to analysis and reporting. Pamela Lowe and Antje Lindenmeyer contributed to analysis.
Funding: Economic and Social Research Council project grant (L218252038); part of the innovative health technology programme.
Competing interests: None declared.
Ethical approval: Warwickshire local research ethics committee and Hartle-pool and North Tees local research ethics committee.
References
Fox RC. Medical uncertainty revisited. In: Bendelow G, Carpenter M, Vautier C, Williams S, eds. Gender, health and healing: the public/private divide. London: Routledge, 2002: 236-53.
Willis J. The paradox of progress. Oxford: Radcliffe Medical Press, 1995.
Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women. JAMA 2002;288: 321-33.
Rosenberger NR. The process of discourse: usages of a Japanese medical term. Soc Sci Med 1992;34: 237-47.
McWhinney IR. An acquaintance with particulars... Fam Med 1989;21: 296-8.
Gorovitz S, MacIntyre A. Toward a theory of medical fallibility. J Med Philos 1976;1: 51-71.
Beresford E. Uncertainty and the shaping of medical decisions. Hastings Cent Rep 1991;21: 6-11.
Tanenbaum S. What physicians know. N Engl J Med 1993;329: 1268-71.
Tanenbaum S. Evidence and expertise: the challenge of the outcomes movement to medical professionalism. Acad Med 1999;74: 757-63.
Tanenbaum SJ. Knowing and acting in medical practice: the epistemological politics of outcomes research. J Health Polit, Policy Law 1994;19: 27-44.
Haynes RB, Devereaux PJ, Guyatt GH. Physicians' and patients' choices in evidence based practice. BMJ 2002;324: 1350.
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