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A faulty production line

This fearmongering over missed cancers will end up costing us GPs

Dr Samir Dawlatly

There are many aspects of the job that cause me anxiety, but I tend to worry most about missing a diagnosis of cancer. As a perfectionist, I hate getting anything wrong, especially a diagnosis as important as cancer.

I should probably accept that I will get it wrong sometimes, and when I do it will inevitably lead to a misdiagnosis, a delayed diagnosis and even the death of a patient. It doesn’t sit comfortably with me and I can think of at least two patients that I have seen in the last few years that have had a diagnosis of cancer missed by me.

So perhaps I am being understandably touchy when I get annoyed by the mainstream press reporting that two-thirds of cancer diagnoses are missed by GPs. Behind the headline, I suppose what this means is that only a third of bowel and lung cancer diagnoses are made via the ‘two-week wait’ pathway for suspected cancers.

Now patients may simply not see a GP before a diagnosis, cancers may be diagnosed incidentally on imaging arranged for another reason. Patients may be so sick that they need admission to hospital. Patients may become unwell between the time of referral for investigation and the date of their outpatient appointment.

We can miss the cancer needle in the growing haystack of patient demand

But it's also worth remembering that patients and their symptoms don’t always follow the textbook. Vague symptoms, atypical symptoms, absence of symptoms and diagnostic overshadowing can all mean that we can miss the cancer needle in the growing haystack of patient demand. One could also argue that growing GP workload means that we are prone to decision fatigue and therefore more likely to miss diagnoses and misdiagnose.

The alternative to acting as the prudent gatekeepers of the NHS and being its risk sink is to simply refer more. Refer anybody with vague symptoms, a slight change in their bowel habits or a bit of bloating after a curry. This will both overload secondary care, who struggle just as much as general practice with workload and workforce issues, and have a massive psychological impact and knock-on effect on our patients.

What rips my knitting the most, though, is the impact that the spinning of such 'research' has on morale. I have no doubt that it makes already hard-pressed GPs wonder why they bother. It may well be the final nail in the career of a young or experienced GP. But bad news and fearmongering sells papers and generates clicks.

The conspiracy theorist in me can’t help but wonder who would bring the attention of the mass media to an article in a low-impact Dutch epidemiology journal. Either it’s the publicity-seeking cancer charities who funded it, or it's Richmond House exerting yet more leverage over a beleaguered profession.

Dr Samir Dawlatly is a GP partner in Birmingham

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Readers' comments (5)

  • No sweat, I am sure our highly trained noctor, phoctor and paramocter colleagues will fare better in this regard.

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  • Bob Hodges

    Breast screening and bowel screening and cervical screening pick up a large proportion of cancers......and they don't count as 2 week wait cases either.

    To imply that these have been 'missed by GPs' is fuckwittery of the extreme calibre so often demonstrated by the gin-soaked simpletons masquerading as a 'free press' in this country.

    My reserves of fucks left to give about when a post-NHS future arrives and what it looks like are becoming conspicuous by their absence. Ou tax bills may well become much larger, but they will be easier to pay when we are free of the abuse of obligated philanthropy.

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  • The imam or chaplain will sort it and we can clean up the mess as usual and get all the blame.

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  • The must-read that explains the mess we are in
    "Over Diagnosed making people sick in the pursuit of health" by Gilbert Welch. These arguments are the real crisis in healthcare, not privatization or models of funding. The debate should be about benefit, and what is causing harm. Creating a nation of worried well is harm.

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  • Ivan Benett

    Since we work in a probabilistic discipline we will always risk missing some diagnoses, and over diagnosing sometimes. Its the nature of medicine, especially for low prevalence conditions.
    Our responsibility is to enable access, use investigations wisely, safety net and take people seriously when they keep coming back with the same problem.
    All of these are harder to do in an under resourced service. This is why better resourced services tend to do better at early diagnosis than we do. We should also undertake Significant Event Analyses on every misdiagnosis, or cancer that presents in ED, to see if there was anything that could have been done better.
    Don't beat yourself up, but see if there is anything in our control that could improve earlier pickup.

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