I’m an Uncertainty Specialist

I had a fascinating discussion with a middle-aged woman in my practice recently. She had been told by our practice nurse that she had pre-diabetes and had been prescribed metformin, a drug used to reduce blood sugar levels. She wanted to speak to me to understand what ‘pre-diabetes’ meant. She was really angry. ‘Have I got a disease or not, Dr Marshall’ she asked ‘and do I have to take these silly tablets?’

These are good questions. I could have introduced a bit of artificial certitude (a George Bushim) into the consultation but for once I wasn’t running late. I felt like answering yes, you have, and no, you haven’t to first question and maybe, but maybe not, to the second. Classic answers to questions that arise from the zone of uncertainty that GPs operate in for so much of the time. The fundamental problem, which I appreciated only later that evening over a glass of wine with my wife, was that I thought we were preventing a disease by prescribing metformin but she thought I was giving her one.

My uncertainty problem is that screening for pre-diabetes is both a good and a bad thing, a paradox. Most importantly, it is an arbitrary judgement. The cut off point for diagnosing so-called pre-diabetes was recently reduced by a group of experts in the United States from a fasting glucose of 6.0 per cent to one of 5.7 per cent. Overnight this increased the prevalence of pre-diabetes by 3 fold. Does this sound OK? Are we creating illness?

Huxley said that ‘medical science has made such tremendous progress that there is hardly a healthy human being left’. So where do you stand? Are you a disease deny-er or a disease monger? Good GPs can only make sense by being both. At the same time. The paradox of being an uncertainty specialist.

Martin Marshall
GP, Newham
Professor of Healthcare Improvement, UCL