Clinical casebook: One more thing should I pay for a scan?
Jane Brown is 44 and has consulted you about a mole and a minor shoulder injury. 'While I'm here, doctor, I'm thinking of paying to have a bone scan of my heel. There's a place advertising them in town and I was wondering whether you think it would be worthwhile. Or do you think you could arrange one on the NHS for me?'
How do we feel when we get a request like this?
Probably irritated if we have used up all the appointment time doing an MRCGP job on her mole and shoulder problems! One option is to invite her to come back to 'give this the time it needs'. Dealing with it here and now will produce a satisfied patient and avoid taking up another appointment; but you may not deal fully with the problem, you might end up running late anyway and give the impression that it's acceptable to cram too many problems into one consultation.
- What issues do private tests raise? Patients who need NHS tests but ask to have them done privately rarely pose much of a problem. However, patients who self-refer to private companies often do not realise the implications (some of which also apply to NHS outsourcing of diagnostics). If you recommend or sanction the test you may be accepting responsibility for the outcome.
- Will the patient be fully counselled about the accuracy of the test and the implications of a positive or negative result (PSA testing is a good example)?
- How robust is the quality assurance? Would you be confident to treat/not treat Jane if the scan suggested osteoporosis?
- Who is responsible for informing the patient and acting on the result?
- How should the GP react if an unsolicited positive test result arrives in the post?
- Is the patient actually entitled to an NHS test instead? (GPs have a duty to provide necessary care under nGMS.) This may impact on practice-based commissioning.
- What is our ethical position if the patient wants to pay for a test which the NHS considers of little proven value?
- How much time should an NHS GP devote to discussing, for example, hair analysis for allergies?
- What are the risk factors for osteoporosis?
NICE guidelines cover secondary prevention of osteoporosis, and recommend treatment for women aged between 65 and 74, if osteoporosis is confirmed with a DEXA scan. Guidelines for primary prevention, including who should have DEXA scanning, are due to be published this year. NICE recommends bisphosphonates for women under 65 only if their bone mineral density is very low (a T-score of -3 SD or below), or if they have confirmed osteoporosis and one or more of these risk factors: ·
- they are very underweight; BMI of less than 19kg/m2
- their mother had a hip fracture before the age of 75
- they had an early menopause that was untreated ·
- they have a condition that increases the risk of osteoporosis such as rheumatoid arthritis, chronic inflammatory bowel disease, hyperthyroidism or coeliac disease
- they have a medical condition that doesn't allow them to move.
Most doctors would now also consider osteoporosis risk assessment, DEXA scanning and/or treatment in women with:
- previous fragility fracture
- X-ray evidence of vertebral deformity or osteopaenia
- premature menopause, secondary amenorrhoea for >1 year (pregnancy excluded), primary hypogonadisim (and primary or secondary hypogonadism in men)
- treatment with oral glucocorticosteroids for more than three months
- history of anorexia nervosa
- history of heavy smoking or drinking
- significant family history of osteoporosis.
Other relevant sources include the National Osteoporosis Society, which has published a Primary Care Strategy for Osteoporosis and Falls, and the national service framework for older people (Standard 6 is intended to reduce the number of falls that result in serious injury and ensure effective treatment and rehabilitation for those who have fallen) .
What osteoporosis prevention advice should you offer Jane?
- Eat a balanced diet, rich in calcium and vitamin D; supplements if she can't do this
- Take regular weight-bearing exercise (30 minutes' brisk walking five times a week or equivalent)
- Don't smoke, and drink within safe limits (14-21 units/week)
- Get adequate, safe sunshine exposure (15 minutes daily; avoiding midday sun)
- Consider HRT if her menopause comes early· Advise on falls prevention if she is at risk
Melanie Wynne-Jones is a GP in Marple, Cheshire
- Patients often have unreasonable expectations of what can be achieved in a 10-minute consultation. Active time management is an important GP skill.
- Consider the implications before sanctioning private investigations.
- Women (and men) should be assessed proactively for osteoporosis risk factors, offered advice on prevention, and referred for DEXA scanning as appropriate.
- Adults should be offered opportunistic osteoporosis prevention advice.