Clinical Uncertainty in Primary Care

This is a book about primary care clinicians and the clinical uncertainty endemic to their work. Even when seemingly straightforward, each patient raises unique questions regarding how best to listen to their complaints, empathize with their suffering, or respond to their silences.

This book is also about addressing uncertainty in primary care practice and engaging it. Engagement requires knowledge, explicit and tacit, placed in the service of a single patient's problem. It also requires carefully managed communication, facilitating dialogue with the patient and encouraging shared problem-solving.

Most importantly, this book is about collaborative engagement with case-based uncertainty in the setting of small groups of clinicians. Sommers and Launer contend that the medical profession's tradition of working independently should be augmented with an explicitly shared, collegial one of jointly creating wisdom through practice-based learning.

An international panel of expert clinicians and educators provides:

• Perspectives on clinical uncertainty in the medical literature
• A taxonomy of clinical uncertainty with patient examples
• Analysis of the educator role to support clinicians in engaging uncertainty
• A compendium of small group methods for collaborative engagement with clinical scenarios
• Analysis of the special challenges of collaborative engagement A mind-opening manifesto, Clinical Uncertainty in Primary Care will equip primary care clinicians, educators, public health and behavioral health professionals with resources for infusing practice with meaning through collegial collaboration.

From the Foreword: "Lucia Sommers and John Launer, with the accompanying inputof their contributing authors, have done a deeply insightful and close to exhaustive job of defining clinical uncertainty. They identify its origins, components, and subtypes; demonstrate the ways in which and the extent to which it is intrinsic to medicine...and present a cogent case for its special relationship to primary care practice...Clinical Uncertainty in Primary Care not only presents a model of collegial collaboration and support, it also implicitly legitimates it." Renee Fox, Annenberg Professor Emerita of the Social Sciences, University of Pennsylvania

Autorentext

Lucia Siegel Sommers is an educator and health services researcher with a 40-year history of working with clinician small groups. She holds an undergraduate degree from the University of Pennsylvania; a masters in social work from Bryn Mawr University; a doctorate in public health from the University of California, Berkeley and completed a 2-year fellowship in health services research at Stanford University. From 1994 through 2001, Lucia was a full-time faculty member in the Internal Medicine Residency Program at St. Mary's Medical Center in San Francisco and Associate Program Director from 1997 to 2001. She is currently an assistant professor in the Department of Family and Community Medicine at the University of California San Francisco where she has taught medical students since 1996. Her published research includes studies focused on the effectiveness of medical audit, nurse-physician collaboration to improve care and reduce costs in hospitals and interdisciplinary care for the frail elderly in the primary care office setting.

John Launer is a family physician, family therapist, educator and writer. He graduated in English at Cambridge before studying medicine at London University. After obtaining Membership of the Royal College of General Practitioners with distinction in 1983, he worked for 22 years as a GP in Edmonton, north London, and continues to work as a part-time GP. In 1994 he completed training at the Tavistock Clinic as a family therapist and joined the senior staff there as honorary consultant in general practice and primary care. Since then his teaching and clinical work has drawn together ideas from family medicine and family therapy, with a focus on narrative and clinical supervision. John is an Associate Dean for Postgraduate Medical Education at London University, and has published five previous books as author or editor, including 'Narrative-Based Primary Care: A Practical Guide.' He has lectured and run workshops internationally, including in the USA, Canada, Scandinavia, Israel and Japan.

Zusammenfassung

The Power of Colleagues

What happens when primary care clinicians meet together on set aside time in their practice settings to talk about their own patients?

.....Complimenting quality metrics or performance measures through discussing the actual stories of individual patients and their clinician-patient relationships

In these settings, how can clinicians pool their collective experience *and apply that to 'the evidence' for an individual patient?*

.....*Especially for patients who do not fit the standard protocols and have vague and worrisome symptoms, poor response to treatment, unpredictable disease courses, and/or compromised abilities for shared decision making*

What follows when discussion about individual patients reveals system-wide service gaps and coordination limitations?

.....Particularly for patients with complex clinical problems that fall outside performance monitors and quality screens

How can collaborative engagement of case-based uncertainties with one's colleagues help combat the loneliness and helplessness that PCPs can experience, no matter what model or setting in which they *practice?*

.....And where they are expected to practice coordinated, evidence-based, EMR-directed care

These questions inspired Lucia Sommers and John Launer and their international contributors to explore the power of colleagues in Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement and offer antidotes to sub-optimal care that can result when clinicians go it alone.

From the Foreword: Lucia Sommers and John Launer, with the accompanying input of their contributing authors, have done a deeply insightful and close-to-exhaustive job of defining clinical uncertainty. They identify its origins, components and subtypes; demonstrate the ways in which, and the extent to which it is intrinsic to medicineand they present a cogent case for its special relationship to primary care practice'Clinical Uncertainty in Primary Care' not only presents a model of collegial collaboration and support, it also implicitly legitimates it.'' Renee Fox.

Inhalt
Section One: Clinical Uncertainty in Primary Care1.Introduction.- 2.Uncertainty and Clinical Method.- 3.Learning about Uncertainty in Professional Practice.- Section Two: The Challenge of Engagement4.Balint Groups and Peer Supervision.- 5.Research on Balint groups.- 6.The Thistle and the Maple Leaf: PBSGL in Canada and Scotland.- 7.Narrative-Based Supervision.- 8.Training in Narrative-based supervision: Conversations inviting change.- 9.Practice Inquiry: Uncertainty Learning in Primary Care Practice.- 10.Using Practice Inquiry to Engage Uncertainty in Residency Education.- 11.We're all in the same boat: Potentials and Tensions When Learning Through Sharing Uncertainty in Peer Supervision Groups.- 12.Case-Based Learning in Swedish Primary Health Care: Strengths and Challenges.- 13. Afterword.