Unrelieved uncertainty

The only certain thing about medicine is its uncertainty. Patients and doctors must make decisions on the available information, which is always incomplete, variably relevant to individual circumstances, hedged around with likelihoods, best bets, and gut feelings, balanced by individual preferences, and constrained by available resources. Somehow, sometimes, good decisions are made.

With careful use of evidence, and diligent clinical care, we can reduce uncertainty, but we will never remove it entirely. The BMJ’s Uncertainties series (bmj.com/specialties/uncertainties-page) explores clinical questions for which clear research evidence is lacking and suggests what to do in the face of this uncertainty. Recent articles have asked whether adults should take vitamin D to prevent disease (currently there is no clear evidence of benefit in musculoskeletal outcomes), whether tranexamic acid improves outcomes in traumatic brain injury (again, no clear evidence of benefit), what the most effective treatment for frozen shoulder is (insufficient evidence to recommend one), and whether we should screen extensively for cancer after unprovoked venous thrombosis (probably not). How helpful this is, you must decide. Our aim is to identify areas of research based uncertainty, to stimulate and inform future research, and to open up space for shared decision making.

This week’s Uncertainties article asks whether to offer gabapentin to women with unexplained pelvic pain (doi:10.1136/bmj.j3520). From their literature review, Andrew Horne and colleagues find no strong direct evidence to support its use and conclude that its safety is also uncertain. This spares patients and doctors from using a drug that’s likely to be ineffective and may be harmful. But it leaves them with the problem of managing this common and distressing condition. James Duffy provides some guidance (doi:10.1136/bmj.j3624). He recommends a combination of pharmacological, physical, and cognitive behavioural therapy “directed towards achievement of higher function with some pain rather than a cure.”

The BMJ’s Rapid Recommendation series (bmj.com/specialties/rapid-recommendation) also aims to reduce uncertainty and accelerate the uptake of research into practice. This week’s contribution asks whether steroids are helpful for people with sore throat (doi:10.1136/bmj.j4090). Incorporating data from a recent randomised controlled trial, the authors’ systematic review and meta-analysis (doi:10.1136/bmj.j3887) concludes that a single dose of oral corticosteroid reduces the severity and duration of symptoms but made no difference to the number of days off work or school. Given the low cost and low likelihood of harm from a single dose, they suggest this as an option to discuss with patients. Gareth Iacobucci summarises the Rapid Recommendation (doi:10.1136/bmj.j4333).