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I've always understood the essence of general practice to be about managing uncertainty. When medical students spend time at our surgery, I try to convey to them the way in which general practice differs from specialist care and how central this concept of uncertainty is. I've been fond of quoting to them (not necessarily accurately), Marshall Marinker's observation that in general practice we marginalise danger, while specialists increase certainty. I'm beginning to wonder whether I should stop. I may be able to live with uncertainty, but my patients don't want to know about probabilities, they want certainty, they want answers and they've got the internet.
Never mind that there is so much about health out there on the world wide web, and that they'll have visited a wholly indiscriminate selection of sites. Nor that much of what is on offer has little or no quality assurance. Indeed, Wikipedia, the 17th most trafficked site on the net and a popular reference source for my patients, represents a ‘consensus’ in which expertise has no currency. As web entrepreneur and author, Andrew Keen argues, we are creating an endless digital forest of unreliable mediocrity that people increasingly rely upon as their main source of information.1
No, what gets me is that their problem is rarely a clear, distinct clinical disorder, and even less often serious. Indeed, in the spirit of imitation being the sincerest form of flattery, I propose the digital successor to Julian Tudor Hart's Inverse Care Law — that the size of pre-consultation web search is inversely related to probability of a definitive diagnosis. I'm even willing to add a sub-clause on the relationship to social class. When the second most affluent residential area in the North East materialised on our practice doorstep in the early 1990s, a day didn't go by without some cyberchondriac offering you as a decision aid a thick wedge of fanfold, perforated-margin paper, with that unreadable dot-matrix print. Our role was to do the tests, make the referral or prescribe the treatment that the websites recommended. It brought a new edge to addressing the patient's ideas, concerns and expectations.
Much of what we do as GPs is to deal with non-specific problems. Often these develop over time into something that is a recognisable entity, like watching a photographic print emerge in a bath of developing solution. Good clinical skills enable the GP to respond early, confidently and accurately. We have to ensure that these skills are present by the end of vocational training. Judging by the recent experience of the simulated surgery element of the MRCGP, that is not yet always the case.2 We also want research that adds to our understanding of what is going on, that sheds light on some of the uncertainties that we encounter in clinical practice.
This year's Paper of the Year does just that. It addresses a problem encountered almost every day in general practice, that of the child with a persistent cough. The authors found that over a third of the children studied had evidence of recent whooping cough infection, even though nine out of 10 had been vaccinated against the illness. Few had a classical whoop, though most had a spasmodic cough with vomiting.3 The messages are important for us as GPs. We should think about pertussis in children whose cough has persisted for 2 weeks or more, because if it is the cause, we can tell the parents that the cough is likely to be protracted. We are less likely to misdiagnose, and therefore mistreat the problem as asthma. Lastly we can consider the possible risk of transmission to newborn siblings.
Individual pieces of research only sometimes change practice, perhaps less often than should be the case. From time to time a study hits the bullseye, becomes a tipping point, opens your eyes to what is going on, and means that the next time you see that problem in surgery you deal with it differently and better. That is what we look for in the RCGP's Paper of the Year. I think that once again we found it.