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Haslam's view: Catching up with past mistakes

Now that every consultation in the practice is recorded on computer, with incoming letters scanned and every consultation being apparently paperless, I don't often get to see the old handwritten medical records of my patients.

But every now and again, either when I have to complete an insurance report, or I am puzzled by a case and want to look back through a patient's entire medical history, then the old scribbled note cards appear.

The Lloyd George record cards are now primarily of historical interest. The wealth of social and personal history recorded on these millions of pieces of cardboard is something that I hope society can preserve for future generations of historians. But I still sometimes have to look at the old records of patients who have been in my practice their entire lives, and I'm faced with all my mistakes.

In my defence, many of them weren't mistakes when I made them, but they are now. The retrospectoscope has been cruel and the truth has been exposed.

Perhaps I had better explain.

The other day I was faced with the records of a 30-year-old man whose insurance report I needed to complete. He was taking out a mortgage, but the first time I had treated him was for nappy rash, shortly after he was born. And there, in the first few years of his life, were an absurd number of consultations, typically in my handwriting, treating his recurrent night-time cough with course after course of unnecessary ampicillin.

However I look at it, the drugs were probably not needed.

Now I know differently. The chances are that not one of those ‘chest infections' was actually a chest infection at all; they fizzled out as he got older, his mother suffers from asthma, and he had eczema at the time. I have little doubt that

I was failing to diagnose childhood asthma, but then, back in those olden days, a recurrent night-time cough was not recognised as a sign of asthma. It's hard to imagine that something as obvious as a clinical symptom was not recognised as relatively recently as 30 years ago, but it wasn't.

However, it is entirely possible that these episodes of recurrent cough actually weren't asthma either. Research has shown that many of these episodes are actually attenuated whooping cough, even in children who have been immunised. The researchers concluded that we should consider diagnosing more school-age children presenting with a cough lasting more than two weeks as whooping cough sufferers. So I would probably have been wrong if I had seen him five years later and had diagnosed childhood asthma after all.

And so it goes for more of our consultations than we can ever realise. Looking back at today's diagnoses from 30 years in the future, who knows which diagnoses will have been discarded? I certainly can't see irritable bowel syndrome still existing as a condition; it will have been subdivided into at least half a dozen entirely distinct conditions, each with separate physical aetiologies. And migraine, depression, anxiety, diverticular disease and countless others will have been unravelled to show us just how curious our current treatments really are.

But we can only do the best we can with the knowledge we have at the time, so I don't feel too embarrassed by those missed cases of childhood asthma, or whooping cough, or whatever it turns out to be.

It's something quite different that will embarrass me. I just don't know what it is yet.


Professor David Haslam CBE
GP, Ramsey, Cambridgeshire; President, Royal College of General Practitioners; national clinical adviser to the Healthcare Commission; and visiting professor at de Montfort University, Leicester

Catching up with past mistakes

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