Family physicians are more comfortable with uncertainty

Family physicians told us they are more comfortable with uncertainty than the “ologists.” For a little history, the Future of Family Medicine project published in 2004 identified this mental attribute as an important defining skill of family physicians.

This ability manifests itself across the entire spectrum of family medicine.

An example is reassuring a young mother that her infant with a fever will probably be fine – and ordering no tests or hospitalizations. Another is reassuring a middle-age man, who had a neck CT ordered by an ER doctor after a minor motor vehicle accident that revealed a smooth cystic mass in his thyroid gland, that he doesn’t need to worry about it (and if there is any follow up, it’s minimal and as non-invasive and inexpensive as possible), family physicians make a dozen decisions a day to not order tests or treatments that other physicians would.

This doesn’t mean that family physicians are simplistic in their thinking and don’t understand that in each of these cases rare outcomes happen rarely. Rarely, a child who initially looks mildly ill worsens over the next day or so. Rarely, a smooth mass seen on imaging turns out to be cancer.

It’s just that family physicians also feel that overtesting and overtreating, besides causing great economic harm to society, also  harm patients. Infants indiscriminately prescribed antibiotics experience adverse effects individually, and across all patients bacterial resistance to antibiotics worsen. People who have surgery for benign-appearing masses suffer the predictable risks of surgery, including death. Movements such as the Avoiding Avoidable Care organization and conference have helped spread this message better than the during the fiasco of the managed care era.

And medical schools certainly don’t teach or value this skill. Think about how many times the presentation of a patient with a rare disease in a medical school M&M conference run by one of the bigoted ologists started with a statement that, “this patient was referred to us by a local MD (medical school speak for family physician) who discovered an X on one of his patients” — the implication being that the “local MD” just doesn’t know enough to know what should happen next. Medical schools teach thoroughness, not judgment or prudence.

Medical students who have poor tolerance of uncertainty find a primary care career too challenging. I also believe this comfort is a huge reason mid-levels can never achieve the efficient outcomes of family physicians. They refer to ologists any patient situation that doesn’t fit one of their cookbook algorithms.

This family physician characteristic is so important that the AAFP should spend much more of its resources on spreading this message: that family physicians provide better care at a lower cost because they as medical decision makers are more comfortable with uncertainty than all other physicians (internists included). This is a huge undertaking. I’m asking the AAFP to make efforts to move the U.S. cultural dial to a different place than it currently is. This means the AAFP will have to fight back against the influence of Dr. Oz and the rest of the TV doctors and health beat reporters.

Because if the family physician is comfortable with the uncertainty that a patient with a classic migraine history doesn’t need a dose of radiation to her head (a CT scan), but she is not comfortable with the inherent uncertainty of this decision (the physician can’t be certain that the CT will find no mass) then conflict will arise between patient and physician. The family physician will  not receive a 10 on the patient satisfaction report card, which some bureaucrat will interpret as poor care.

And a sustainable well-supported army of U.S. family physicians will continue to only be wishful but delusional thinking. If our patients and the payers don’t support our comfort with uncertainty, we will continue to be an anemic presence in U.S. healthcare system.

Richard Young is a physician who blogs at American Health Scare.

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  • ninguem

    All sorts of variations on this joke.

    Internist, family doc, and a surgeon went duck hunting.

    A bird flies by, the surgeon shoots it, and sends it to the pathologist to tell him what kind of bird it was.

    Another bird flies by, the internist takes aim and says, “by the wing span and plumage, it’s likely to be a duck, but must rule out swan, rule out goose, rule out penguin, rule out pterodactyl…..” and the bird was out of sight.

    Another bird flies by, and the family doc empties his shotgun on the bird, BANG, BANG, BANG, BANG…..and this clump of mangled flesh and feathers flops to the ground.

    “I don’t know what it was, but I sure got it.”

  • Suheir Kilani

    Very nice article and yes it is the truth that family doctors are comfortable with uncertainty. And ninguem has also explained in a very funny and witty way.

  • Adolfo E. Teran

    Dear Doctor Young, it was very nice to read about how Family Docs work and live. Adolfo E. Teran, MD ( Orange Doc Family Medicine)

  • FugaziedUp

    The author’s presumption that midlevels, by way of their chosen profession, are incapable of thinking other than algorithmically, is as simple-minded and short-sighted as he presumes midlevels to be…other than that, a great article!

  • Tom

    Family physicians are more comfortable with uncertainty, and because patients like me have come to know and trust our family physicians, WE are more comfortable with THEIR “uncertainty”.

    Never ever underestimate how important a commodity trust is. The reason I would not think of making a fuss if my doc says, “I don’t think you need” this test, or that drug, or whatever… is that I have come to know and trust him, and since over the years he has been treating me he has been right far more often than wrong, I know that he is putting all of his considerable knowledge about both medicine and about me to work and making the best possible decision.

    The problem is that such trust takes a while to develop. If I have to start seeing a different miscellaneous “provider” every time I go in, and am no longer allowed to see my real doctor, I don’t think it’s possible that I would trust someone I have only just met and who is not familiar with me either. I would be more inclined to second guess them.

    Especially if I knew that the reason I was no longer allowed to see my doctor but shunted to one of his “physician extenders” was to save the practice money, then if one of those “physician extenders” who doesn’t know me from Adam says that he or she is going to deny me this test, or that drug, or whatever, I’m much more likely to be suspicious that that decision, too, is all about money rather than my well-being.

    • Cyndee Malowitz

      Could you PLEASE quit referring to NPs/PAs as “physician extenders.” That sounds like some kind of sexual device.

  • Samir

    Now I feel like I was born to be a Family physician. Think common and think simple first. But never forget the ‘Red flags’.

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