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CAMHS won't see you now

Unsanctioned PSA test comes back highly positive

Three GPs share their approach to a clinical problem

Case history

The first thing you know about Mr Bryant's prostate problems is when his highly positive PSA test result lands in your in-tray. On reviewing his records you see he is age 55 and recently saw the health care assistant for routine monitoring of his hypertension. She has recorded: 'Patient would like prostate cancer test – blood sample sent.'

His blood pressure was perfect, and he is not due to come in for another check for six months. You don't know Mr Bryant, but practice policy is to tell patients to ring in for test results in a week.

Dr Rupal Shah

'This opens a Pandora's box – the value of PSA testing is complicated at the best of times'

The health care assistant has opened a Pandora's box! It would obviously have been much better if Mr Bryant had been counselled about the pros and cons of PSA testing so he could have made an informed choice about whether to have it done.

It would be useful to know why he wanted the test in the first place. Does he have symptoms of prostatic disease? Is there a family history of prostate cancer? I think I would first review his notes to see whether there is anything significant in his medical history.

After this, I would feel obliged to make an exception to the practice's usual policy and contact Mr Bryant directly, probably by letter, and invite him to come in to discuss the results of his blood tests.

Assuming he responds to this invitation, the first thing would be to elicit how much he already knows about PSA testing and his reasons behind requesting it. I would need to take a history of any relevant symptoms and, ideally, examine him. The value of PSA testing is a complicated subject at the best of times, and it's far from ideal to have to explain the implications of a high result after, instead of before, a positive test.

In terms of what to do next, it depends on the actual PSA result. If it's very high, not borderline, I would need to refer him to a urologist straightaway. But otherwise it might be more sensible to repeat the test in a few weeks. Mr Bryant will need as much written information as possible.

This case highlights the need for us to review our practice policy on PSA testing so a similar situation doesn't crop up again; in particular, adequate pre-test counselling needs to be carried out by a GP or practice nurse.

The health care assistant needs to be made aware of this, as does anyone else who routinely takes bloods in the practice.

Rupal Shah completed the VTS in 2002 and is a GP in west London

Dr Melanie Wynne-Jones

'If this is a first occurrence I would see it as a training need that we should have anticipated'

If Mr Bryant rings in and is told to make an appointment with the doctor, he is going to wonder why and will have an unpleasant wait. However, he may be so alarmed that he puts pressure on the receptionist to allow him speak to a doctor immediately. This is not an ideal way to break bad news, and it won't be any better if I ring him myself.

An alternative may be to send an apparently standard letter: 'Your results are back; please make an appointment with the doctor.' Either way, as a failsafe I would follow up to ensure he does attend.

When he comes in I would attempt to find out why he asked for the test, whether he has any symptoms and what he knows about prostate cancer screening.

Ideally, the health care assistant should have told him he would need to see the doctor before he could have a blood test, and informed one of the partners of his inquiry. I could then have taken a proper history, examined him as appropriate and counselled him about the pros and cons.

I would also have offered him a choice of the Government's one-, three- or five-page prostate screening information leaflets, which are available on the internet or as a PILS leaflet. I would try to cover some of this ground, but because Mr Bryant's PSA is so high, we would also need to discuss his feelings and the next step, which would be an urgent referral under the two-week rule.

For the practice, this is a significant event. I would not have expected the health care assistant to have done what she did. She was probably trying to be helpful, and if this is the first occurrence I would see it as a training need that we should have anticipated.

If, however, she appears regularly to be acting outside her competence, the practice must deal with this quickly and effectively.

Melanie Wynne-Jones has been a GP for 20 years and is a GP trainer and appraiser in Marple, Cheshire

Dr Robin Fox

'As no pre-test counselling was done, I am looking at the least bad way to break bad news'

Should one of my partners know Mr Bryant well I would ask them to speak to him. Otherwise I would find out from the computer as much as I could about him and his family and do it myself.

If his PSA is above 10ng/ml he has a 50-60 per cent chance of having prostate cancer. Pre-test counselling, which should always be done, has not happened and so now I am looking at the least bad way to break bad news.

At age 55 it is likely Mr Bryant will be at work. I could communicate with him by telephone or letter, but I would instead go round to his house at the end of surgery tonight to speak with him. This would allow us to talk face to face and avoid us being disturbed.

If Mr Bryant consented I would arrange a 'two-week wait' appointment with the urology team to arrange a biopsy. I'd explain to him what this involved and would arrange a follow-up meeting over the next few days.

Later I would speak to the health care assistant and our nurse practitioner to see what went wrong. It's important to emphasise that this is a system failure and not her fault. She may need our support.

I would complete a significant event analysis form and bring this scenario anonymously to our next practice team meeting. We would discuss the events in order to learn from them and hopefully avoid this happening again.

At present if patients ask for a PSA test I counsel them about the pros and cons. I then give them the Cancer Research UK patient information leaflet, with the option of a more in-depth leaflet.

After reading this they choose whether to attend for a PSA test, and a follow-up consultation is organised automatically to discuss the result. I would be happy to change this protocol if the team comes up with something better.

Robin Fox completed the VTS in July 2002 and is a partner in Bicester, Oxfordshire

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