MPS, like the NHSLA has experienced a rise in the number of claims being made over recent years. Twenty-two per cent of claims made against MPS GP members in 2010 included cancer as the primary underlying patient illness.1
A problem with the diagnosis of the disease featured in almost half of these claims with failures to refer, and failures to adequately assess the patient being the top two causes of the ‘misadventures’ leading to claims being brought. Breast cancer made up 12% of all cancers in GP claims in 2010 as opposed to 7% for melanoma and 4% for colon.
It is Friday afternoon at 5pm. You’re running about 30 minutes behind, having dealt with several of your more ‘challenging’ patients One of your colleagues has called in sick and you’ve had a few of his patients added on to your list. You’re a little stressed to say the least, but glad that it is the weekend. Your next patient, Mrs Knot, comes in and tells you that she was checking her breasts the other day and had noticed a lump. She’s a 45 year old lady, who you have seen before, with a history of panic attacks and she looks particularly anxious today. On talking to her, it is clear why: her friend recently had a mastectomy and has been through chemotherapy. Mrs Knot is terrified that the lump she has found is cancer.
You take a history and ascertain that she is due her period in two weeks time. She has no family history of breast cancer whatsoever. You ask her where the lump is and she points to her right breast. Reception is very busy as it is flu season and there is no one available to chaperone you for at least the next ten minutes or so. You decide that as you’re running extremely behind and she has another appointment booked with you in two weeks for a different problem, you’ll ask her to wait for her next period and if the lump is still there then you will examine her and refer her on for a specialist opinion.
Unfortunately, Mrs Knot books a last minute holiday and forgets that she has her appointment with you in two weeks time. She was uncharacteristically reassured by your explanation at the last consultation and doesn’t re-present to the practice until three months later, when you do examine her and notice a lump in her axilla as well. You experience a sinking feeling at this point, and decide to call your defence organisation for advice, after referring her under the two-week referral system.
1 Make time to do an exam
The most common diagnostic feature in breast cancer is the note of a lump being found by a patient.
NICE released their referral guidance for suspected cancer in June 2005 and this includes recommendations for breast cancer.1 This states that the physician should examine the lump with consent, and although benign lumps are common and may cause anxiety, an urgent referral would not be appropriate in women aged younger than 30. In women older than 30 years, a discrete lump, which persists after the next period, or appearing after menopause, mandates an urgent referral.
Case histories similar to the one above are all too familiar. In such scenarios, the temptation to not examine during a very busy and stressful day leaves GPs wide open to criticism, should a complaint or claim be made. Robust mechanisms for follow up in such cases are very important, along with a clear discussion about what is expected of the patient in terms of follow up, and this then needs to be written clearly as part of the medical record.
2 Remind the patient to attend appointments
These are the type of consultations where checking patient understanding is critically important and it may be helpful to suggest a patient makes an appointment for follow up prior to leaving the surgery to ensure that a time and date is fixed, for peace of mind. Clinicians should make it clear to the patient that if they cannot make that appointment for any reason, then they should either make an appointment as soon as possible, or if this is not possible then to at least discuss it with one of the GPs, so that it is flagged as a potential problem for follow up referrals.
3 Improve you and your colleagues’ confidence
Another potential problem for GPs is ‘professional embarrassment’, when clinicians in secondary care write to GPs with feedback following referrals, which they have felt were inappropriate or unnecessary. This could leave the doctor in primary care, who is without a specialist diagnostic kit or expertise, with doubt as to the appropriateness of further referrals of breast lumps.
This ‘hesitation’ is clearly concerning and potentially jeopardises patient safety. If you face such a situation, perhaps the best approach would be to open up a dialogue with the local breast clinic as to the best way forward for both parties.
Organising teaching from the breast clinic for GPs in the locality may be helpful for all and this would then create a forum for the GPs to address any difficulties they may face with such cases directly with the specialists.
Perhaps conduct an audit of all breast lump referrals to ascertain whether or not they are in line with local and national guidance. This will help ensure that systems are being correctly followed; that you are referring appropriately and reinstall self-confidence where it may have been lost.
Dr Zaid Al Najjar is a medico-legal advisor to MPS.
1 NICE guidline. Referral for suspected cancer. http://www.nice.org.uk/cg027