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全科医学中的不确定性及管理策略

高可音 史威力 王留义

高可音, 史威力, 王留义. 全科医学中的不确定性及管理策略[J]. 中华全科医学, 2024, 22(8): 1267-1271. doi: 10.16766/j.cnki.issn.1674-4152.003614
引用本文: 高可音, 史威力, 王留义. 全科医学中的不确定性及管理策略[J]. 中华全科医学, 2024, 22(8): 1267-1271. doi: 10.16766/j.cnki.issn.1674-4152.003614
GAO Keyin, SHI Weili, WANG Liuyi. Uncertainty and it's management strategies in general practice[J]. Chinese Journal of General Practice, 2024, 22(8): 1267-1271. doi: 10.16766/j.cnki.issn.1674-4152.003614
Citation: GAO Keyin, SHI Weili, WANG Liuyi. Uncertainty and it's management strategies in general practice[J]. Chinese Journal of General Practice, 2024, 22(8): 1267-1271. 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
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

Uncertainty and it's management strategies in general practice

  • 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。

     

  • 图  1  医学不确定性的来源及关系

    Figure  1.  Sources and relationships of medical uncertainty

  • [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.
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出版历程
  • 收稿日期:  2024-02-29
  • 网络出版日期:  2024-11-19

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