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At the heart of general practice since 1960

Haslam's view: Don't miss the rare bird among the pigeons

You were probably exposed to a similar ritual when youwere at medical school.

I can still picture it: a haughty teaching hospital doctor – probably quite junior – was teaching a group of us, and I was cornered and asked what I thought the rash covering the patient in front of us might be.

I was flustered, not to mention clueless, and named something exceedingly rare – tertiary syphilis, I think. I don't recall the details of my ignorance, just that it was pretty deep.

And at that my teacher pointed out of the window to a bird on a distant chimney pot, and asked me what I thought it was. Before I could say a word, he said, ‘I suppose you'll be telling me it's a hummingbird, won't you? Never forget that common things occur commonly. It's a pigeon.'

Ignoring the fact that I was pretty sure that it wasn't a pigeon, the point was well made. Common things occur commonly. Don't diagnose hummingbirds when the trees are full of pigeons.

Except that hummingbirds, or their diagnostic equivalent, have the nasty habit of consulting GPs and we have to know when and how to spot them. Even if we don't realise they are hummingbirds, we need to know when and where to seek a second opinion.

I once had a patient who had a condition so rare that at the time there were only seven reported cases in the world. Over the past couple of weeks, my partners have seen a patient with a neurological condition with a prevalence of around 1 in 100,000.

And all of us have seen cases that are unique – the only one presenting in that particular way in the world. It's not fair, is it? But it's certainly interesting.

Think of your most recent surgery. Yesterday, I saw a woman who had brought her daughter for me to look at her swollen glands. But then she said ‘while I'm here, doctor...' and showed me a rash that she said had almost certainly come on while gardening, but which I am absolutely certain is actually necrobiosis lipoidica.

Now, you may think there is nothing unusual about a case like that, but when you think of how she presented, and what her history was, and what the signs and symptoms were, and what my impression was, then the mass of variables is extraordinary.

The task of having to spot the pattern among the complexity is much greater than we sometimes recognise. Somehow, we have to identify the underlying patterns while avoiding stereotyping that reduces our patients' individuality.

Patients live in the community, not tertiary care units. And the community is that bit of the medical universe we call home.

So when you look out of the surgery window and see that bird on the distant chimney pot, remember that it might be a macaw.

And even if it really is a pigeon, the next one along may not be.

Tough, isn't it?

Author

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

All of us have seen cases that are unique – the only one presenting in that way in the world

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