全科医学中的不确定性及管理策略

高可音; 史威力; 王留义

doi:10.16766/j.cnki.issn.1674-4152.003614

全科医学中的不确定性及管理策略

doi: 10.16766/j.cnki.issn.1674-4152.003614

郑州大学人民医院全科医学科，河南郑州 450000

基金项目:

河南省医学科技攻关计划软科学项目 RKX202101001

郑州市科技计划项目 2021KJHM0022

详细信息

通讯作者:
王留义，E-mail：wly2000@126.com

中图分类号: R499
计量
- 文章访问数: 18
- HTML全文浏览量: 7
- PDF下载量: 1
- 被引次数: 0
出版历程
- 收稿日期: 2024-02-29
- 网络出版日期: 2024-11-19

Uncertainty and it's management strategies in general practice

Department of General Practice, People's Hospital of Zhengzhou University, Zhengzhou, Henan 450000, China

摘要

摘要: 在当今医学领域，不确定性普遍而广泛存在于医疗保健系统。其可以出现在诊疗的各个环节，以各种形式，通过不同方式影响医生和患者，进而影响诊疗效果，是医疗服务过程中的极大挑战。达成面对医疗不确定性的共识，有利于建立持久的、以信赖为基础的医患关系，实现双方利益平衡。全科医生作为一般患者的首诊医生，面临着多样化疾病谱和患者个体差异等挑战，如何管理不确定性问题成为全科医生日常工作的一部分，掌握不确定性的管理策略对于全科医生显得尤为重要。然而，目前对医学不确定性的系统研究非常有限，国内大部分研究局限于不确定性在某项技术或某个过程中的应用，缺乏相关综合性论述，对不确定性管理策略的分析整合鲜少提及，为此笔者作了一项系统文献综述，以探索适用于全科医学的不确定性管理策略。本文从医学不确定性的来源和影响对其进行分析，进而对如何在临床决策中管理医学不确定性，在不确定性中制定适宜的临床决策进行讨论。笔者认为各种来源的医学不确定性会导致医患双方情绪、行为、反应的负面效应，通过采取合适的管理策略有可能减轻医学不确定性及其造成的影响，对不确定性背景下的临床决策有一定的参考意义。
- 医学不确定性 /
- 全科医生 /
- 管理策略 /
- 临床决策
Abstract: Uncertainty is pervasive within the healthcare system in medical filed nowadays. It impacts all aspects of diagnosis and treatment, affecting doctors and patients in various ways. Establishing a consensus on medical uncertainty facilitates the establishment of enduring doctor-patient relationships based on trust balance the interests of both parties, thereby influencing the efficacy of diagnosis and treatment. This poses a significant challenge in medical services. As the initial clinicians for the patients, General Practitioners are faced with challenges of managing a wide range of diseases and accommodating individual patient differences. Effectively navigating uncertainty is an integral part of their daily responsibilities, making the mastery of uncertainty management strategies particularly crucial for general practitioners. However, the current research on medical uncertainty is severely limited, with most domestic studies focusing on the application of uncertainty in specific technologies or processes. Comprehensive discussions and analysis and integration of uncertainty management strategies are lacking. Therefore, we conducted a systematic literature review to explore applicable uncertainty management strategies in general practice. This article analyzes the origins and ramifications of medical uncertainty and explores approaches to manage it during clinical judgments. We posit that medical uncertainty from various sources can negatively affect the emotions, behaviors, and reactions of both healthcare professionals and patients. However, adopting appropriate management strategies can mitigate these effects, providing a reference for clinical decision-making under the background of uncertainty.
- Medical uncertainty /
- General practitioners /
- Management strategy /
- Decision-making

HTML全文

图 1 医学不确定性的来源及关系

Figure 1. Sources and relationships of medical uncertainty

下载: 全尺寸图片幻灯片

参考文献(52)

[1]	HAN P K J, BABROW A, HILLEN M A, et al. Uncertainty in health care: towards a more systematic program of research[J]. Patient Educ Couns, 2019, 102(10): 1756-1766. doi: 10.1016/j.pec.2019.06.012
[2]	SCOTT I A, DOUST J A, KEIJZERS G B, et al. Coping with uncertainty in clinical practice: a narrative review[J]. Med J Aust, 2023, 218(9): 418-425. doi: 10.5694/mja2.51925
[3]	PICKLES K, CARTER S M, RYCHETNIK L, et al. General practitioners' experiences of, and responses to, uncertainty in prostate cancer screening: insights from a qualitative study[J]. PLoS One, 2016, 11(4): e0153299. DOI: 10.1371/journal.pone.0153299.
[4]	GARDNER N P, GORMLEY G J, KEARNEY G P. Learning to navigate uncertainty in primary care: a scoping literature review[J]. BJGP Open, 2024. DOI: 10.3399/BJGPO.2023.0191.
[5]	STROUT T D, HILLEN M, GUTHEIL C, et al. Tolerance of uncertainty: a systematic review of health and healthcare-related outcomes[J]. Patient Educ Couns, 2018, 101(9): 1518-1537. doi: 10.1016/j.pec.2018.03.030
[6]	JOHNSSON L, NORDGREN L. The voice of the self: a typology of general practitioners' emotional responses to situational and contextual stressors[J]. Scand J Prim Health Care, 2022, 40(2): 289-304. doi: 10.1080/02813432.2022.2097616
[7]	SIMPKIN A L, KHAN A, WEST D C, et al. Stress from uncertainty and resilience among depressed and burned out residents: a cross-sectional study[J]. Acad Pediatr, 2018, 18(6): 698-704. doi: 10.1016/j.acap.2018.03.002
[8]	BEGIN A S, HIDRUE M, LEHRHOFF S, et al. Factors associated with physician tolerance of uncertainty: an observational study[J]. Gen Intern Med, 2022, 37(6): 1415-1421. doi: 10.1007/s11606-021-06776-8
[9]	KORENSTEIN D, SCHERER L D, FOY A, et al. Clinician attitudes and beliefs associated with more aggressive diagnostic testing[J]. Am J Med, 2022, 135(7): e182-e193. doi: 10.1016/j.amjmed.2022.02.036
[10]	BEGIN A S, HIDRUE M K, LEHRHOFF S, et al. Association of self-reported primary care physician tolerance for uncertainty with variations in resource use and patient experience[J]. JAMA Netw Open, 2022, 5(9): e2229521. DOI: 10.1001/jamanetworkopen.2022.29521.
[11]	GELLER G, TAMBOR E S, CHASE G A, et al. Measuring physicians' tolerance for ambiguity and its relationship to their reported practices regarding genetic testing[J]. Med Care, 1993, 31(11): 989-1001. doi: 10.1097/00005650-199311000-00002
[12]	BERESFORD E B. Uncertainty and the shaping of medical decisions[J]. Hastings Cent Rep, 1991, 21(4): 6-11. doi: 10.2307/3562993
[13]	LEE C, HALL K, ANAKIN M, et al. Towards a new understanding of uncertainty in medical education[J]. J Eval Clin Pract, 2021, 27(5): 1194-1204. doi: 10.1111/jep.13503
[14]	SIMPKIN A L, SCHWARTZSTEIN R M. Tolerating uncertainty: the next medical revolution?[J]. N Engl J Med, 2016, 375(18): 1713-1715. doi: 10.1056/NEJMp1606402
[15]	MALTERUD K, GUASSORA A D, REVENTLOW S, et al. Embracing uncertainty to advance diagnosis in general practice[J]. Br J Gen Pract, 2017, 67(659): 244-245. doi: 10.3399/bjgp17X690941
[16]	HOFMANN B. Temporal uncertainty in disease diagnosis[J]. Med Health Care Philos, 2023, 26(3): 401-411. doi: 10.1007/s11019-023-10154-y
[17]	MCMAHON C J, SENDŽIKAITẼ S, JEGATHEESWARAN A, et al. Managing uncertainty in decision-making of common congenital cardiac defects[J]. Cardiol Young, 2023, 33(3): 502. DOI: 10.1017/S1047951123000185.
[18]	吕健. 医疗的确定性、不确定性与医患共同决策[J]. 医学与哲学, 2021, 42(12): 5-10. LYU J. The certainty, uncertainty of medicine and shared decision-making[J]. Medicine & Philosophy, 2021, 42(12): 5-10.
[19]	MAKHNOON S, SHIRTS B H, BOWEN D J. Patients' perspectives of variants of uncertain significance and strategies for uncertainty management[J]. J Genet Couns, 2019, 28(2): 313-325. doi: 10.1002/jgc4.1075
[20]	BLUESTEIN D, LEVIN J S. Symptom reporting in wanted and unwanted pregnancies[J]. Fam Med, 1991, 23(4): 271-274.
[21]	MAYOU R, SPRIGINGS D, BIRKHEAD J, et al. Characteristics of patients presenting to a cardiac clinic with palpitation[J]. QJM, 2003, 96(2): 115-123. doi: 10.1093/qjmed/hcg017
[22]	OZAWA N, SATO K, SUGIMURA A, et al. Quality of life in patients with nonalcoholic fatty liver disease: structure and related factors focusing on illness uncertainty[J]. Jpn J Nurs Sci, 2021, 18(3): e12415. DOI: 10.1111/jjns.12415.
[23]	KIM O, YEOM E Y, JEON H O. Relationships between depression, family function, physical symptoms, and illness uncertainty in female patients with chronic kidney disease[J]. Nurs Health Sci, 2020, 22(3): 548-556. doi: 10.1111/nhs.12691
[24]	HVLYA D, KEVEN A, ALKAN E. Patients risk factors and pulmonary nodule characteristics in the differentiation of malignant pulmonary nodules[J]. Med Sci Pulse, 2023, 4(16): 1-5.
[25]	李建国, 郭慧, 宋津晓. 临床指南的选择与患者的个体化医疗[J]. 医学与哲学, 2021, 42(2): 1-5, 80. LI J G, GUO H, SONG J X. On the selection of clinical guidelines and individualized medicine[J]. Medicine & Philosophy, 2021, 42(2): 1-5, 80.
[26]	杜建. 医学知识不确定性测度的进展与展望[J]. 数据分析与知识发现, 2020, 4(10): 14-27. DU J. Measuring uncertainty of medical knowledge: a literature review[J]. Data Analysis and Knowledge Discovery, 2020, 4(10): 14-27.
[27]	ZHOU A Y, ZGHEBI S S, HODKINSON A, et al. Investigating the links between diagnostic uncertainty, emotional exhaustion, and turnover intention in general practitioners working in the United Kingdom[J]. Front Psychiatry, 2022(13): 936067. DOI: 10.3389/fpsyt.2022.936067.
[28]	CARLETON R N, NORTON M A P J, ASMUNDSON G J G. Fearing the unknown: a short version of the intolerance of uncertainty scale[J]. J Anxiety Disord, 2007, 21(1): 105-117. doi: 10.1016/j.janxdis.2006.03.014
[29]	LOWENSTEIN M, VIJAYARAGHAVAN M, BURKE N J, et al. Real-world lung cancer screening decision-making: barriers and facilitators[J]. Lung Cancer, 2019(133): 32-37.
[30]	BLANCH-HARTIGAN D, VAN EEDEN M, VERDAM M, et al. Effects of communication about uncertainty and oncologist gender on the physician-patient relationship[J]. Patient Educ Couns, 2019, 102(9): 1613-1620. doi: 10.1016/j.pec.2019.05.002
[31]	VAN SOMEREN J L, LEHMANN V, STOUTHARD J M, et al. Oncologists ' communication about uncertain information in second opinion consultations: a focused qualitative analysis[J]. Front Psychiatry, 2021, 12: 635422. DOI: 10.3389/fpsyg.2021.635422.
[32]	GILLMAN A S, SCHARNETZKI L, BOYD P, et al. Perceptions and tolerance of uncertainty: relationship to trust in COVID-19 health information and vaccine hesitancy[J]. J Behav Med, 2022, 46(1-2): 40-53.
[33]	SMITH A K, WHITE D B, ARNOLD R M. Uncertainty: the other side of prognosis[J]. N Engl J Med, 2013, 368(26): 2448-2450. doi: 10.1056/NEJMp1303295
[34]	KASSE G E, HUMPHRIES J, COSH S M, et al. Factors contributing to the variation in antibiotic prescribing among primary health care physicians: a systematic review[J]. BMC Prim Care, 2024, 25(1): 8. DOI: 10.1186/s12875-023-02223-1.
[35]	DHAWALE T, STEUTEN L M, DEEG H J. Uncertainty of physicians and patients in medical decision making[J]. Biol Blood Marrow Transplant, 2017, 23(6): 865-869. doi: 10.1016/j.bbmt.2017.03.013
[36]	郭永松, 华淑芳. 医疗风险、责任与对策[J]. 医学与哲学, 2003, 24(4): 1-4. GUO Y S, HUA S F. Medical risk, liability and countermeasure[J]. Medicine & Philosophy, 2003, 24(4): 1-4.
[37]	STEPHENS G C, SARKAR M, LAZARUS M D. Medical student experiences of uncertainty tolerance moderators: a longitudinal qualitative study[J]. Front Med, 2022(9): 864141. DOI: 10.3389/fmed.2022.864141.
[38]	O' RIORDAN M, DAHINDEN A, AKTURK Z, et al. Dealing with uncertainty in general practice: an essential skill for the general practitioner[J]. Qual Prim Care, 2011, 19(3): 175-181.
[39]	BLISSETT S, SKINNER J, BANNER H, et al. How do residents respond to uncertainty with peers and supervisors in multidisciplinary teams? Insights from simulations with epistemic fidelity[J]. Adv Simul(Lond), 2024, 9(1): 8. DOI: 10.1186/s41077-024-00281-8.
[40]	DAHM M R, CATTANACH W, WILLIAMS M, et al. Communication of diagnostic uncertainty in primary care and its impact on patient experience: an integrative systematic review[J]. J Gen Intern Med, 2023, 38(3): 738-754. doi: 10.1007/s11606-022-07768-y
[41]	PATEL B, GHEIHMAN G, KATZ J T, et al. Navigating uncertainty in clinical practice: a structured approach[J]. J Gen Intern Med, 2024, 39(5): 829-836.
[42]	GORDON G H, JOOS S K, BYRNE J. Physician expressions of uncertainty during patient encounters[J]. Patient Educ Couns, 2000, 40(1): 59-65.
[43]	李云涛. 医患共同决策的最佳践行者: 全科医生[J]. 医学与哲学, 2018, 39(3): 19, 67. LI Y T. The best experts of share decision-making: general practitioners[J]. Medicine & Philosophy, 2018, 39(3): 19, 67.
[44]	JOHNSON M W, GHEIHMAN G, THOMAS H, et al. The impact of clinical uncertainty in the graduate medical education (GME) learning environment: a mixed-methods study[J]. Med Teach, 2022, 44(10): 1100-1108.
[45]	HAFIZ A M, SENTURK E, TEKER C, et al. Factors affecting the level of reflective thinking and clinical decision-making skills in medical faculty students[J]. Sisli Etfal Hastan Tip Bul, 2023, 57(4): 543-551.
[46]	PATEL P, HANCOCK J, ROGERS M, et al. Improving uncertainty tolerance in medical students: a scoping review[J]. Med Educ, 2022, 56(12): 1163-1173.
[47]	薛英利, 薛婷, 唐臻娜, 等. 反思性写作服务于全科医学生叙事医学能力培养实践[J]. 中华全科医学, 2018, 16(6): 1011-1014. doi: 10.16766/j.cnki.issn.1674-4152.000277 XUE Y L, XUE T, TANG Z N, et al. GP undergraduates ' narrative competency development via reflective writing[J]. Chinese Journal of General Practice, 2018, 16(6): 1011-1014. doi: 10.16766/j.cnki.issn.1674-4152.000277
[48]	FRIEDRICHS M, SHOSHI A. History and future of KALIS: towards computer-assisted decision making in prescriptive medicine[J]. J Integr Bioinform, 2019, 16(3): 20190011. DOI: 10.1515/jib-2019-0011.
[49]	REIS-DENNIS S, GERRITY M S, GELLER G. Tolerance for uncertainty and professional development: a normative analysis[J]. Gen Intern Med, 2021, 36(8): 2408-2413.
[50]	STREET R L, VOLK R J, SMITH Q W, et al. The professional medical ethics model of decision making under conditions of clinical uncertainty[J]. Med Care Res Rev, 2013, 70(Suppl 1): 141S-158S.
[51]	CARR D, GORMLEY G J. "Visiting uncertainty": an immersive primary care simulation to explore decision-making when there is clinical uncertainty[J]. Educ Prim Care, 2022, 33(4): 237-243.
[52]	李建国, 吕畅, 赵茜, 等. 浅谈临床思维不确定性及其应对策略[J]. 医学与哲学, 2019, 40(21): 14-17. LI J G, LYU C, ZHAO Q, et al. Discussion on the uncertainty of clinical thinking and its coping strategies[J]. Medicine & Philosophy, 2019, 40(21): 14-17.