Clinical Uncertainty in Primary Care: The challenge of collaborative engagement

Chapter 99

Practice Inquiry: Uncertainty Learning in Primary Care Practice

On-line Resource #5

Inputs to Judgment Table

Lucia S. Sommers, DrPH

This document provides guidance for using the Inputs to Judgment Table, the sole ‘prop’ used in PI colleague group meetings. (See Figure 1.) Included in this document are questions specific to each table section that colleagues use to explore the five input to judgment arenas. The questions are framed with the intent to shift colleagues’ gazes away from the usual ways of ‘seeing’ and ‘knowing’ to more creative and imaginative stances.

The five-sectioned tableallows space for noting inputs to judgment in each of the 5 arenasconcerning the case-based uncertainty that colleagues discuss during a colleague group meeting. When documented on the Table, the inputs become available for discussion and analysis, connecting and distinguishing their various dimensions in the interests of engaging theuncertainty presented to the group. Where on the Table a particular input contribution from a colleague goes is less important than assuring that each input finds a place on the Table. The following definitions of Table sections help guide where todocument input contributions: (See Figure 2 for Table completed for the PI colleague group scenario described in Chapter 8.)

  1. Clinical Experience

Inputs that relate to colleagues’ insights from caring for their own patients belong in this section. Examples include: (From completed Table)

-My experience with older old men having AMI’s for the first time: heart failure is not always easy to appreciate

-But this patient is ‘vital’’

-My experience - all depends on the patient’s other co-morbidities

  1. Patient-Clinician Relationship

Inputs that relate to the nature of the presenter’s and patient’s relationship and how that relationship is important for addressing the uncertainty belong in this section. Examples include: (From completed Table)

-You care about each other!

-Lucky to share common interest (soccer)

-Would he understand about overlooking ↑lipids?

  1. ‘The Evidence’ (Including local expertise and resources)

Inputs that relate tothe medical knowledge and skill ‘unknowns’ that could be useful for addressing the uncertainty belong in this section. Also, local expertise and resources of potential value are noted here.Examples include: (From completed Table)

-Value of BNP test?

-Value of cardiac rehab?

  1. Presenter’s Context

Inputsthat relate to what the case presenter uniquely brings to the uncertainty case belongin this section. Examples include: (From completed Table)

-(Presenter)Can’t believe didn’t see cholesterol.. Alert system working?

-Uncomfortable with older heart failure patients....what about you?

-(P)Pharmacist gave me regular updates on his DM – in reasonable control --- assuring

-His AMI surprised you….

-(Presenter) My older brother – unexpected AMI then died at home

  1. Patient’s Context

Inputs that relate to what the patient uniquely brings to the uncertainty belong in this section. Examples include: (From completed Table)

-(Presenter) He’s not himself

-Could he be worried about himself?

-Still taking walks?

-Lights up when you talk soccer?

Inputs to Judgment Table

Section-Specific Questions

  1. Clinical Experience

The questions below help colleagues get in touch with their own past clinical experience with patients such as the one being presented.Colleagues could answer these questions for themselves first and then consider posing one or two of them to the case presenter.

What is the lurking zebra in this case? (e.g., worse case scenario)

What is my experience/knowledge with this disease/ illness/condition/symptom?

What “scripts” or rules of thumb do I use when faced with dilemmas like this one?

In my gut, what do I think is going on? (If I’m right, what should be happening next?)

What pieces of the picture don’t fit?

What are the potential errors down the line should I should be thinking about now?

With what caveats do I pass on my experience to the case presenter?

How urgent is it that the uncertainty is dealt with now? If not, what would be a reasonable timeline?

What other factors make this uncertainty especially compelling? (e.g., patient is taking costly medication of unclear benefit)

  1. Patient-Clinician Relationship

In reflecting upon the case presenter’s relationship with this patient,colleagues could ask:

How would you characterize the relationship you have with this patient?

How would you characterize the extent to which the patient and you trust one another, have similar goals regarding health care, and can effectively communicate with one another?

If you and the patient had the perfect clinician-patient relationship, how would that affect the way you dealt with this uncertainty?

What are the limits of your care-giving role for this patient?

If you unexpectedly found yourself with more time to spend with this patient in the visit, what would you do with the extra time?

  1. ‘The Evidence’ (Including local expertise and resources)

In reflecting upon what could be available in the clinical literature, through local area expertise or resources,colleagues could ask:

What general kinds of ‘evidence’ would most inform your uncertainty? (e.g., review article, clinical guidelines, clinical trial data, local resources for one-on-one consultation)

Where could evidence/expertise reside to inform the uncertainty around this case? Is it accessible? Is it worth making the effort to look for it?

If you could find an article in the literature that would help with this uncertainty, what would be its title?

  1. Case Presenter’s Personal Context

In reflecting upon the case presenter’s personal context regarding this patient, colleagues could ask:

Have you “been here before”? (e.g., found yourself faced with similar dilemmas to this one in the past)What have you usually done? Did you already try that? What happened?

How confident are you about the quality of your data gathering? (e.g., have you engaged the patient in such a way so as have the best chance of learning what you need to know?)

What emotions does this patient evoke in you?

What stereotypes does this patient engender in you?

What expectations do you have for this patient as regards 1) giving you information, 2) understanding you instructions, 3) complying with your advice, 4) wanting to solve their problem

What are your worse fears? What data would allay those fears?

How would having more resources available help reduce the uncertainty? What are these resources and how would you use them, especially the role of other members of the health care team?

  1. Patient’s Context

In reflecting upon this patient’s unique context, colleagues could ask:

Who is the patient that this disease has?

(e.g., personality, job, daily routine, interests/hobbies, health-related behaviors, health literacy, self-efficacy for health care decision making, cultural/religious background, educational level, socio-economic status)

To what extent do you think that the patient had told her/his whole story? What is still unknown?

For what kinds of ill health or further problems is this patient most at risk? (Also consider issues of patient safety)

How is the patient’s behavior an overall response to coping with life? How should that response be dealt with as regards planning future care?

What does the patient say that she wants? (e.g. information, empathy, assurance based on evidence, validation, support)

What is the patient most afraid of happening?

What does the patient know about your uncertainty?

What would change about the nature of your uncertainty if the patient were a different gender, age, culture, have more or less education, or have more or less financial resources?

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