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Letter of the week: Pathology variation down to poor practice

Dr Robert Morley is severely misinformed when he seeks to justify wide variation in pathology tests. (Yet another stick to beat us with) The truth is that variation is down to poor practice.

When one individual in a multi-partner practice has investigation rates four times those of his peers, he has a problem.

When the phlebotomist expresses surprise the locum is requesting so many tests, the locum has a problem. When the number of tests requested by general practice has increased enormously, the profession has a problem.

My observation is that defensive medical practice is driving the desire to exclude everything at the expense of rational practice.

The time-honoured practice of history taking leading to a differential diagnosis, investigated by appropriate examination and then clarified by targeted testing and imaging, has been replaced by minimal history taking, differential diagnoses from an undergraduate textbook, blanket laboratory screening and unnecessary referral.

The fault lies in the failure to deal with uncertainty, which results from insufficient clinical exposure in training caused by restricted working hours, part-time training and a reluctance to accept responsibility for dealing with patients' anxieties.

The result of the QOF and internet misinformation is a belief in the infallibility of tests and the dumbing down of clinical acumen.

What is needed are competent doctors with the courage to practise the skills they have learned who do not bow to the demand for every test because it can be done.

From Dr John Orchard, Alfreton, Derbyshire

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