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The fiendish complexity of general practice

A case of CJD close to home illustrates what is often forgotten in the myopic debate over GP pay and QOF points, says Nigel Praities.

Writing about the NHS every day it is easy to become blasé about medicine, but occasionally someone tells you a story that makes you realise what a hard job it is to be a GP.

A work colleague has a 23-year-old friend who has recently been diagnosed with CJD. His prognosis is bleak and at the moment he can hardly speak or move.

Initially, he refused to go to his GP and then (after his mother forced him) he went, complaining of stress, irritability and a change to his gait.

Eventually, he was referred to a neurologist and an MRI was recommended – but it took a while for him to persuade his GP that this was the best course of action. Eventually, when he was scanned, the results confirmed a diagnosis of new variant CJD.

He is now going for pioneering brain surgery in Edinburgh, with a very low chance of success. But some chance, at least.

How can GPs be best prepared to recognise rarer diseases – diseases they may encounter once if at all in a professional career spanning decades?

I spoke to Professor Richard Knight, director of the National CJD Surveillance Unit at Western General Hospital in Edinburgh, and he said although the average GP would see from zero to one case of CJD in their working life, they still play an important role in picking up cases, particularly where there is a family history (in the case of genetic CJD).

‘The early presentations are not specific to CJD and there are many more common causes of, say, progressive cognitive impairment or ataxia,’ he said.

‘The role for a GP is, in my view, to recognise that their patient has a significant brain disease and to refer to a neurologist.’

Which on the whole, they do. But GPs see dozens of patients each day, and every ten minutes have to separate the routine and the banal from the potentially life-threatening, balancing clinical awareness against their crucial gatekeeper role.

It just shows general practice is both messy and unpredictable, and about much more than notching up QOF points and following NICE algorithms – a point lost when the Daily Mail blusters over GP pay and when researchers cry ‘foul’ over exception reporting.

A difficult, shocking story – and one which illustrates the fiendish complexity of a GP’s job.

Nigel Praities is deputy editor of PulseToday

Nigel Praities