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GPs go forth

Beware of thin notes

Dr David Turner

‘Beware of the middle-aged man with thin notes.’

That was one of the best pearls of wisdom I received as a trainee GP.

For those younger GPs who don’t remember the (blissful) days of paper notes, the old Lloyd George paper records came in a thin card folder. This folder would gradually thicken as the patient aged. A middle-aged patient, particularly if male, with thin notes - ie) an infrequent attender - made us sit up and pay attention, as it would more often than not mean they had something seriously wrong with them.

I was reminded of this recently by a nurse practitioner who, like me, had grown up in the Lloyd George days. She had noted the unusual occurence of a patient with a virtually blank computer screen - the equivalent in the computer age of thin notes.

They had only a four-week history of hip pain and fevers. Blood tests, X-rays and a MRI scan were quickly arranged and revealed pelvic infiltration, most likely lymphoma. A staging CT followed soon, after which showed infiltration of kidneys, spleen and liver. Following this, there was a bone biopsy, result inconclusive. Next step, a liver biopsy, result awaited.

For the first time in my life, I’m on the other side of the fence - I’m lucky, in that this is the first time I’ve been seriously ill

And this is where I’m up to at the moment. Because for the first time in my life, I’m on the other side of the fence; I am the patient with thin notes.

I’m lucky, in that this is the first time I’ve been seriously ill in my life. I’m fortunate to have supportive colleagues, who allow me to take a nap in the middle of the day at work - a malignant illness is tiring. Pain can be controlled with analgesia, but there is nothing to do for fatigue, but rest.

Maybe I’m biased, but every health professional I’ve been treated by so far has been friendly, capable, efficient and filled me with confidence. Bone marrow and liver biopsies hurt, but not as much as you might expect. Uncertainty and waiting for the histology reports is frustrating.

Any criticisms? Navigating the administration of appointment times and clinics can be confusing and exhausting - and I understand how the NHS works. How you do this if you’re elderly, confused and alone, I don’t know.

What's struck me the most is how easily a case like mine could've been passed over, owing to my previous good health.

So, GP trainers, when you’ve ticked all the boxes for your trainee, teach them the non-curriculum stuff, the anecdotes and the wisdom you have acquired over the years, which they will not find in any text book or NICE guidelines. Don’t underestimate a gut feeling - it’s way more valuable than any flow chart. Use your brain and think independently - this is, above all, why you are a doctor.

Dr David Turner is a GP in North West London

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Readers' comments (20)

  • Good luck David. Im sure everyone else reading this wishes you the best too!

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  • Yes I second that. Not easy at all. Good luck.

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  • Very best wishes David. This can't have been easy for you to write but you did it well.

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  • David Banner

    A brilliantly devastating article, David.
    What starts as a typical “no nonsense/ common sense” Dr Turner blog dramatically reveals a personal tragedy that is all the more heart breaking for the matter-of-fact/ no fuss attitude of the author, concluding with a valuable lesson for all clinicians.
    Stay strong, David.

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  • Wishing you well, David.
    And thanks for the insightful commentary.

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  • Vinci Ho

    (1) My sincere best wishes , David .
    (2) I always believe that things always happen in our lives for a ‘reason’ . If we can look at that sensibly enough , we actually become ‘wiser’ as a result .
    (3) While in these days , our younger training colleagues are undoubtedly dominated by advancing technology (eventually AI) , the first rule of thumb in medicine is proper and meticulous history taking and then examination . Every situation is a new situation. Yes , there is an argument that continuity of care might create a blind spot because you thought you knew your patient very well. But equally, the awareness of somebody being completely healthy ‘up to now’ from the history simply means we need to be more humbled in exercising our confidence in medicine , facing the probability of ups and downs in life .

    Please get well soon , David

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  • Beautifully written David. We are here for you always, speedy recovery!

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  • Our thoughts go with you best wishes.

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  • Dear David,

    I am so very sorry to hear this.

    Sending you lots of positive and loving vibes. You are amazing to be helping educate others through your experience. Thank you.

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  • PS. I always over investigate infrequent attenders because you know they have self-managed their milder illnesses in the past.

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