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Thanks, NICE. But I don't have 100 years to implement your advice

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Hilarious that NICE’s new guidance on sepsis had the nation’s media displaying all the relevant red flags – febrile, tachycardic, breathless, confused etc - though more because of an opportunity to nail GPs again than any true bacteraemia, obvs.

This reveals a staggering misunderstanding of general practice

Not as hilarious, though, as a comment I saw in the Times when reading the story over this morning’s Shreddies. Something like, we GPs should ‘think sepsis’ in the same way that we think ‘heart attack’ in any patient attending with chest pain, ‘whether five or 50’. Hang on, that can’t be right. 50, yes. Five, no. Mind you, I’d only just got up, bleary-eyed and all that. Probably a misread, then, or, if not, a misquote.

So I checked it out later. And there it is on the NICE website. A Professor of Paediatric Immunology & Infectious Diseases saying, ‘This is just like when people come in with chest pain. Whether you’re five years old or 50 years old, the first thing that goes through a clinician’s mind is, could this be a heart attack?’

Er, no. In the case of the five-year-old, it might be the first thing that goes through the parents’ mind. It might be the first thing that goes through the child’s mind. And it’s definitely the first thing that goes through NHS 111’s mind (or maybe the second, I can’t remember where the ‘Are you pregnant?’ question comes). But it is not the first thing that goes through the GP’s mind.

And there are two good reasons for this. First, what epidemiological data I can find on childhood MI – and, as you can probably guess, there isn’t much - suggests that the average GP will see one every 100 years. Which means I’d have to work nearly three whole careers in general practice to encounter a case, and then it may not come to me, or present with chest pain. And, second, GPs aren’t catastrophists working from protocols. That’s what NHS 111 is for, and that’s why A&Es are overwhelmed. No. We’re trained to take presentations in context, to use common sense and to see and put things in perspective. This does not means assuming every five year old with chest pain has an MI until proven otherwise, it means the opposite.

Not appreciating this reveals a staggering misunderstanding of general practice - which, coming from NICE, is disappointing but unsurprising. On the other hand, it could just have been a throwaway comment. In which case, can we throw it away? 

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield 

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Readers' comments (7)

  • Brilliant!
    'What occurs commonly occurs commonly'
    This is what experienced GPs pick up over time
    Why don't symptom checking websites list the differential diagnoses in descending order starting with what occurs most commonly in large font and decreasing the font size for rarer diagnoses.

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  • I completely agree with points raised in the article and the comments above. And, having been in secondary care not so long ago as part time specialty Doctor, I also have a grim feeling of despair looking into the future of medical profession. The mentality there is very much to stick to the protocol even if common sense advises otherwise. Even very senior Consultants succumb to this. What future our resourceful but under-resourced Primary Care could have?

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  • Completely get the spirit of the blog but interested in avoidable deaths from sepsis versus Optometrist found guilty of manslaughter for missing papilloedema

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  • Vincenzo Pascale

    In Angola where at the moment I'm working every other month, I see a lot of children (of course). The presentation follows a verbal ritual in Portuguese : I feel asthenic, I have cold, fever, cough, chest pain and dyspnea. Come on

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  • Copperfield for prime minister!

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  • GREAT idea, post at 10.12 today.
    Come to think of it, Dr. Copperfield would make an outrageously gifted
    Secretary of State for Health.
    What do you think , Tony?

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder