Like all good GPs, the Jobbing Doctor is haunted by the patients he could have done more for
They say that whilst architects always have to look at their mistakes, that doctors bury theirs.
In physical terms the body is buried, but the memory and the lessons learnt live for ever. I’ll bet there are no doctors out there who don’t think about the mistakes that they have made regularly, and the frequent supply of ‘I went to my doctor 20 times…’ stories which regularly make their appearance in middle-brow and downmarket tabloids: you know the ones I mean.
In general practice we have the most difficult of jobs. It is the sieving out of the serious illness in its early phase, with non-specific symptoms, from the generality of minor symptom management. Generally a symptom that has a positive predictive value (PPV) of greater than 5% can be regarded as significant. Even then, that means 19 out of twenty people with the symptom do not have the disease in question. Haemoptysis, for example, in lung cancer, or bloating in ovarian cancer.
The skill of diagnosis remains firmly embedded in general practice, and the occasional erudite diagnosis made in secondary care does not shift this balance. Secondary care clinicians don’t really understand how much diagnosis is done in primary care, and I can sympathise with them. Most have never had the opportunity to experience high-quality general practice.
The students who sit in with me often hear about the ‘three-legged stool of diagnosis’. This is stool in the furniture sense and not the scatalogical one! The legs are history, examination and investigation. Because we have patchy access to some investigations, the diagnosis by history and examination mean that we remain very good at these skills. I was reminded of this when I referred a patient with an obvious (to me) abdominal mass that the colleague in outpatients could not feel. I knew I was right as I had scanned the patient prior to referral. Subsequently, the mass was felt.
There is little point in doing an examination by hand if the ultrasonic waves paint a better picture, and I remember – as a junior in hospital – only performing perfunctory chest examinations on admitted patients as I knew they would have a chest X-ray. Indeed the more scheming of us would enter the examination data after knowing the chest X-ray result.
‘Ah yes, there is dullness at the left base’ one might think after seeing a large pleural effusion.
I remember a patient who persuaded me not to send him for investigation. I had a nagging feeling that something was going on that I couldn’t put my finger on, although there were no ‘red flag’ (i.e. PPV > 5%) symptoms. It just wasn’t right. I compromised on a review in four weeks, and felt uneasy.
I was right to feel uneasy, as – four weeks later – a red flag symptom did appear. I packed him off to hospital on an urgent referral, and he ended up dying of an unpleasant cancer. That was four years ago. I looked after him (with my hospital colleagues) for all of his illness, and his wife thanked me for my care after he died. I did mention my feeling that I had let him down to his wife, but she would have nothing of it. I was ‘marvellous’.
No, I wasn’t.
I live with that decision to this day. The sensible part of my brain tells me that the cancer was undifferentiated, and the delay did not influence the diagnosis. The emotional part of my brain says I am rubbish, and I let him down.
My mistakes stand, in my eyes, as tall as any ugly skyscraper.
The Jobbing Doctor is a general practitioner in a deprived urban area of England.
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