Numărul curent

Assoc. prof. dr. habil. Mira Florea
Chairman of editorial board of Romanian Journal of Family Medicine

The length of family medicine consultations varies widely internationally and a large portion of the global population has only a few minutes of consultation time with their primary care physicians. Short consultation times negatively affect the quality of patient care, physician workload, and stress.The need for primary care services is increasing as the global population grows, and this, combined with a shortage of general practitioners (GPs), is leading to a trend towards shorter consultation times. A survey of GPs in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the UK and the US reported that over one third of them are dissatisfied with the time available per consultation per patient. GPs suggest that shorter consultations compromise the care provided (1).

It is worrying that 18 countries, comprising 50% of the world’s population, have a reported average length of primary care consultation of 5 min or less. This reflects problems, related to the organization of health systems, workforce, access and coordination (2). For example, in countries such as Pakistan, Bangladesh and China, there is no scheduling system and GPs may perform over 90 consultations per day, with considerable time to provide repeat prescriptions. The short duration of consultations has been responsible for polypharmacy, overuse of antibiotics and poor communication with patients (2,3).

Shorter consultation times reduce the range of services offered in primary care, contributing to increased stress scores of GPs who feel rushed at the end of the consultation.  Average consultation duration is a quality indicator used by WHO and the International Network for the Rational Use of Drugs (INRUD) to promote the safe and cost-effective use of medicines worldwide. Several countries that follow the INRUD method have established their own optimal consultation duration as a quality standard (2).

Longer consultations improve health promotion, lead to more accurate diagnosis of mental health problems, improve quality of life, and motivate patients with multi-morbidities (3).

In the US, few young physicians are interested in pursuing a career in primary care (4) and many practicing family physicians experience exhaustion and burnout and are considering a career change (5).

A recent study (6) reveals the negative experiences and ways in which GPs adapt to limited time and these include:

– unnecessary testing and referrals to mitigate workload overload;

– sacrifices in quality patient care and self-care to cope with and mitigate the effects of workload overload;

– feelings of inadequacy and dissatisfaction due to sacrificing personal standards of healthcare provision due to time pressure;

– feelings of guilt and exhaustion due to limited time allocation in relation to workload.

Professional organizations of family physicians and primary care payers must align the schedule and duration of the consultation with the workload of physicians, not ignore the time dedicated to administrative tasks, introduce flexibility, and establish realistic work expectations in primary care (6).

Establishing an average consultation time in family medicine by WHO and INRUD would be a measure to promote the safe and cost-effective use of medicines, protect doctors and patients, and should be universally reported and accepted as a guarantor of the quality of medical services provided.

 

   Bibliografie/References

1. Mercer SW , Hasegawa H , Reilly D , et al . Length of consultations. Time and stress are limiting holistic care in Scotland. BMJ 2002;325:1241.
2. Irving G, Neves AL, Dambha-Miller H, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017;7:e017902. Available from: doi: 10.1136/bmjopen-2017-017902.
3. Jin G , Zhao Y , Chen C , et al. The length and content of general practice consultation in two Urban districts of Beijing: a preliminary observation study. PLoS One 2015;10:e0135121.Available from: doi:10.1371/journal.pone.0135121.
4. Knight V. American medical students less likely to choose to become primary care doctors. KFF Health News 2019:3. Available from: https://kffhealthnews.org/news/american-medical-students-less-likely-to-choose-to-become-primary-care-doctors/.
5. Abbasi J. Pushed to their limits, 1 in 5 physicians intends to leave practice. 2022;327(15):1435-1437. Available from: doi: 10.1001/jama.2022.5074.
6. Nguyen MT, Honcharov V, Ballard D, Satterwhite S, McDermott AM, Sarkar U. Primary Care Physicians’ Experiences With and Adaptations to Time Constraints. JAMA Netw Open. 2024;7(4):e248827. Available from: doi: 10.1001/jamanetworkopen.2024.8827.

Management of medical uncertainty in modern medicine

Assoc. prof. dr. habil. Mira Florea
Chairman of editorial board of Romanian Journal of Family Medicine

Physicians often face significant uncertainty in modern medicine, despite advances in medical technology, diagnostics, and research.     Medical uncertainty is intrinsic to clinical practice because, as William Osler wrote, „Medicine is the science of uncertainty and the art of probability,” and it affects both young doctors and experienced clinicians (1).

The continuous medical progress, the complexity and, sometimes, the difficulty of solving cases in modern medicine bring decision-making uncertainty for medical professionals.

Uncertainty affects many areas of practice: interpreting ambiguous findings from a growing range of laboratory investigations or those incidental to imaging examinations (CT, MRI), selecting treatment for conditions for which there are several options, assessing disease prognosis, efficient navigation regarding care in a complex health system and the ethical decision regarding the balance between the patient’s desire and the avoidance of risk greater than the benefit and the context of limited availability of resources. It is due to various factors: complex disease presentations, limited or conflicting evidence, patient-specific factors, and evolving treatment options.

The Sources of Uncertainty include:

– Diagnostic Uncertainty: despite advanced diagnostic tools (like imaging, molecular diagnostics, etc.), many diseases present with overlapping symptoms, making definitive diagnosis challenging.

– Prognostic Uncertainty: predicting disease progression or outcomes is inherently uncertain, especially for chronic conditions or cancers, where individual variation plays a large role.

– Therapeutic uncertainty: although there are a variety of treatments, sometimes the guidelines are contradictory and the selection of the best therapeutic formula for a particular patient can be difficult.

– Evolving Evidence: new studies and trials can challenge existing medical knowledge. Physicians must constantly stay updated, but sometimes the evidence itself is incomplete or in flux (2,3,4).

The management of the medical uncertainty is crucial for effective clinical decision-making and patient care.

Strategies for Managing Uncertainty:

– Evidence-Based Medicine (EBM): physicians use evidence-based guidelines in the diagnostic and therapeutic decision-making process. However, they must assess the applicability of the evidence to the patient, recognizing that guidelines may not cover every clinical scenario.

– Shared Decision-Making: Involving patients in decisions allows physicians to incorporate patient values, preferences, and tolerance for risk, especially when multiple treatment options exist with uncertain outcomes.

– Clinical Judgment and Experience: in the face of incomplete data, experienced physicians rely on pattern recognition, and professional intuition developed over years of practice.

– Multidisciplinary Collaboration helps reduce uncertainty by sharing knowledge and perspectives.

Medical professionals must be able to recognize and manage uncertainty in its various forms, communicate uncertainty to patients and discuss   it openly with their colleagues.  Managing uncertainty in modern medicine is multidimensional and requires a balance between scientific evidence, patient values, and clinical judgment. The use of advanced technology, shared decision-making, and continuing education are key strategies that physicians use to manage uncertainty and provide high-quality care.

The current health care design and financing favour medical investigations and procedures over potentially cognitively demanding clinical consultations between physicians and patients and shared decision making in the context of irreducible clinical uncertainty. Physicians and managers must advocate together for care system reforms that support the recognition, acceptance, and management of uncertainty and the means to minimize its potentially harmful effects on patient care and clinician practice (5).

 

   Bibliografie/References

1. Bean RB, Bean WB. Sir William Osler: aphorisms from his bedside teachings and writings. New York: Henry Schuman;1950.
2. Kang SK, Berland LL, Mayo‐Smith WW, et al. Navigating uncertainty in the management of incidental findings. J Am Coll Radiol 2019;16:700‐
3. Haier J, Mayer M, Schaefers J, et al. A pyramid model to describe changing decision making under high uncertainty during the COVID‐19 pandemic. BMJ Global Health 2022; 7: e008854.
4. Stone L, Olsen A. Illness uncertainty and risk management for people with cancer. Aust J Gen Pract 2022;51:321‐
5. Scott IA, Doust JA, Keijzers GB, Wallis KA. Coping with uncertainty in clinical practice: a narrative review. Med J Aust. 2023;218(9):418-425. Available from: doi: 10.5694/mja2.51925. Epub 2023 Apr 23. PMID: 37087692.
6. Scott IA, Doust JA, Keijzers GB, Wallis KA. Coping with uncertainty in clinical practice: a narrative review. Med J Aust. 2023;218(9):418-425. Available from: doi: 10.5694/mja2.51925. Epub 2023 Apr 23. PMID: 37087692.