Managing Uncertainty.

“Patients will sometimes tell us that they had been going to see their GP for six to nine months with, say, a pain in their stomach and were told to go to the pharmacy and buy an over-the-counter medicine (and later are found to have cancer).”

Yes, of course.

In a time honoured strategy, General Practitioners are usually the first to face the wrath of the national media. Nevertheless, there are a few more variables to be accounted for before a successful early cancer diagnosis can be made and it’s not all down to the GP to make it happen. First of all, the patient must tell his or her GP about the new and worrying symptoms he or she might have. While this may sound obvious, there are a couple of reasons why this might not happen. A good example is the comparatively low percentage of men seeing their GP with early red flag symptoms and often presenting in the later stages of a medical problems (1). 

Another reason often cited is patients who ’didn’t want to bother the doctor’. I normally tell these that I’d rather be seeing them a once more than necessary before we miss anything important. And by the way: we’re not ‘bothered’ by our patients. The reason that we’re sitting in the chair in the surgery, seeing forty patients a day is because we chose to do so. If I would be bothered seeing patients I would have chosen a different specialty (without naming one in particular, of course. But as you can imagine, there are a couple of specialties where you can reduce patient contact to a minimum) than General Practice. If you can’t stand the presence of your own patients, then you’re definitely in the wrong job. 

So before making a diagnosis, the doctor has to know about the symptoms. When the General Practitioner then hears about the worrying complaint it is likely that he will request investigations (bloods, xrays, ultrasound, etc) or will refer directly to a specialist. If the complaints are classic red flag symptoms it is highly unlikely that any GP will be ignoring these and telling the patient to go to the pharmacy. That doesn’t necessary mean that GPs never get it wrong, but I’d wager the number is neglectable in these circumstances. But more frequently there are times when the symptoms just aren’t classic red flags. In fact they might be completely unspecific. In that case it is up to the individual practitioner to either investigate, refer or just wait for a week or two.  This is the often quoted ‘Management of Uncertainty’ and is at the heart of General Practice, as most patients arrive with concerns that just don’t fit in any particular category. Medicine is fuzzy and patients rarely have text book presentations of one particular illness. Hence the management of uncertainty bit. And this is obviously the moment where things can go wrong in General Practice. Managing uncertainty is not easy, and GPs will get it wrong at times, no doubt about that. But I am sure this is due to the nature of General Practice, and exceedingly rare due to a single practitioner . 

So let’s say the GP made the appropriate diagnosis and referred the patient. There are still plenty of things that can wrong: the referral might get lost. The appointment letter might get lst in the post. The clinic is cancelled. The Xray machine (MRI/CT-Scanner/USS) is broken. The xray report vanishes. The report from the specialist to the doctor can’t be typed because of staff ilness. And who will then pick up the phone and try to call the various partys? Exactly, it’s the patient’s GP who has a worried patient in his surgery who hasn’t heard anything from the local hospital and will likely sort it out by sweet-talking various members of staff.

 

So there we have it: before blaming GPs for the failures within the NHS, do consider the other factors that might hinder successful cancer detection and treatment.    

Thank you.

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1 Ian Banks: No man’s land: men, illness, and the NHS.  BMJ. 2001 November 3; 323(7320): 1058–1060