Medicine is not a precise science and there is alway uncertainty over the management of the more complex problems. Where there is uncertainty and no clear answer it helps to keep an open mind and enable both the doctor and patient to revisit the diagnosis and management
Despite all the technology and knowledge the gut instinct is still a crucial part of managing each patient. It is an awareness that the pattern does not fit. A sense of uncertainty (which for some people is indeed a sensation in the gut). It is important to surface this feeling. Acknowledge and actively respond to it by stopping and thinking more carefully.
When rushed or under pressure for other reasons it is tempting to brush gut instinct aside, particularly if there are a series of consultations with complex problems or multiple issues. Prior experience can also bias your thinking. You have to stop, think and put time aside to consider what it is that feels wrong and what you are going to do to address this.
Share with you patient the options for what might be the diagnosis and the whole range of options for management. By doing this you are ensuring all possibilities are covered. It means the patient is fully informed and can come back to you if things are not going right. They are also less likely to complain that you missed something serious because you have discussed it. The process of discussing options for diagnosis and management will also help your own thinking. You will then consider a wider range of possibilities, slow down to consider each and justify your actions more clearly.
Clear arrangements for follow up will give you a chance to revisit your diagnosis and management. More clues may become available with time. The duration of the symptoms will reduce the possible causes. In many cases resolution will be reassuring and confirm that observation alone was the correct approach. Your niggle of concern will be addressed and you will be abel to focus on the next patient.
There are pressures against follow up which include pressure on appointments and the opinion of others in the practice who might view follow up as unnecessary. Follow up can just be the offer of review and information on telephone access. You can also check phone details and call later yourself. It is important to document this in the records as absence of follow up is often a medioc-legal criticism on later review. Where you have concerns it is safer to actually give a follow up appointment the next day or week as appropriate. Then you can be certain you have arrangements clearly in place and have done all that you can.
Use other services that you may work closely with for follow up as well such as the district nurse or health visitors. People who are reliable and can link back in with you quickly if they are worried. Try to avoid relying on referral onward without knowing when and how the patient might be reviewed as the system may fail.
One key player is the family. Ask for permission to contact and explain to a relative. Invite them in if they are outside the room. Once in the same room you can then get permission to share the full options for diagnosis and management to establish a true partnership. Bear in mind that the majority of complaints about care come from relatives who were not involved and misunderstand the situation.
The world is imperfect and things will go unexpectedly wrong despite you being the very best doctor in the world. Think it over, learn from any advice, move on with your added experience and remember all the times you got it right.