Posted by: Tony Copperfield27 August 2012
Do not adjust your mindset. At first glance, this column reads more like a clinical tutorial than the usual rantings of a greying and increasingly psychotic coalface GP. It might, therefore, appeal to a whole new demographic – those who can say ‘learning needs’ without a wave of nausea.
It might even attract educational credits – if so, I’d like to retrospectively attach brownie points to a previous piece on managing workload that suggested clearing the waiting room with a Kalashnikov (double credits, remember, if the idea was implemented).
So here’s today’s case: an eczematous four-year-old boy with a fever, non-specific not-wellness and a bizarre rash. You know how when you’re initially perplexed, you get little clues from the history and from eyeballing the patient, and things start to make some sense?
In that you can figure out roughly what’s going on or, at least, dream up something vaguely plausible to send parent or punter away happy while you, ahem, ‘await events’? Well, that didn’t happen.
He just had this weird vesico-pustular rash on his elbows and knees and looked a bit grim. It wasn’t any obvious exanthem. It wasn’t staph-infected eczema. It wasn’t anything I recognised. And I was wrong-footed enough – and he seemed ill enough – to send him in (sold to the paeds as ‘????eczema herpeticum’).
Anyway, the hospital didn’t have a clue, either, and after some days of umming, aahing, swabbing and venesecting, they sent him home, improving, as ‘diagnosis: whatever’.
Fast forward a few weeks. I’m clocking some clinical pics in Pulse, and – bugger me – there it is. Papular acrodermatitis. Some weird viral thing. It was like looking at a photofit on Crimewatch and recognising who I’d been mugged by.
Even more amazing, the article featured a couple more – unilateral hemithoracic exanthem and eruptive pseudoangiomatosis, and no, I’m not making these up – that I’ve also definitely seen and dismissed, slightly uncertainly, as viral. Correctly, as it turns out.
OK, the educationalists can leave the building. Because here’s where I get to rant like a street-corner evangelist. This story, to me, sums up what’s great about general practice – and what’s at risk of being destroyed. I’m not bigging myself up here.
After all, I didn’t actually make any of these three diagnoses. But the one who was ill I sent in, whereas the two who weren’t I didn’t. And disposal is more important than diagnosis, even if that doesn’t create cutesy, clear-cut care pathways.
Besides, if you insist on a clever label for every symptom you’ll need to man the barricades with syndrome-spouting specialists. Or, if you want a risk-averse system, you man – or woman – them with triage nurses, who have an anaphylactic response to uncertainty and so send everything in. Both models of care are favoured by some, and both are budget-bustingly expensive.
Or you could stop dismantling and deconstructing general practice and leave it to those with the knowledge, the experience and the necessary antennae: we GPs know what we know, know what we don’t know and know when not knowing is a no-no.
And for that we deserve credit. Double credits, in fact.
Dr Tony Copperfield is a GP in Essex.