Dr Copperfield considers the value of living with diagnostic uncertainty and the perils of too much access to general practice
Recently, during our daily ritual therapeutic highly caffeinated post-surgery catharsis, a colleague of mine made a comment that really shocked me. What she said, with statutory moans, groans and eye-rolls, was this: ‘OMG, I’ve had one of those mornings where I couldn’t make a single diagnosis.’
Incredible! The fact that she thought this was out of the ordinary, I mean. For me, it’s normal. All my surgeries are like that. And it’s definitely not my fault, it’s the patients. They just routinely churn out a litany of ill-defined dizziness, vague tiredness and non-specific feelings of feeling non-specifically ill. Not only is it impossible to work out the diagnosis, sometimes I can’t even work out who the patient is. In fact, some surgeries are so brain scrambling that they end with me being unsure who or where I am, what this job is and, especially, why I’m doing it.
Ring a bell? Don’t worry. Like I say, it’s standard. And if you want evidence rather than anecdote, get a load of this: somewhere between 30% and 75% of primary care presentations defy diagnosis. I’m not just talking about those persistent, perplexing and inevitably over-investigated problems that eventually end up in the diagnostic dustbin labelled ‘Medically Unexplained Symptoms’. I’m referring to the everyday, minor, transient stuff that isn’t clearly a) viral, b) barn-door obvious or c) depression.
So if you’re not feeling utterly bewildered as a GP, you’re not doing it right. And if it grinds you down, you can draw solace from the fact that the Great Symptom Iceberg means that, for every case of ‘There must be a reason why my right nipple buzzes when I lean to the right and urinate’, there are many more who are tolerating their buzzy nipples without bothering us. So count yourself lucky.
The problem is, if we accept that there really are a lot of symptoms out there, the vast majority of which are harmless, inexplicable and self-limiting, then there is a very strong argument for keeping these people away from primary care. Otherwise – particularly in the hands of those who are less comfy than the average GP with the concept of ‘uncertainty’ (not just noctors, but mainly) – these people will become patients: they’ll get unnecessarily investigated, referred and treated, and we all know that ends in tears.
Currently, there are organisational barriers that prevent this – reasonable delays for appointments, hassle factors, receptionists and so on. If this protection is undermined by making ‘access’ excess and promoting electronic communication, we will open up a Pandora’s box of quasi-pathology and we – GPs and public – will find ourselves in big trouble.
Because that tolerated buzzing nipple, and a multitude of other pseudo-symptoms out there of which we are blissfully unaware, suddenly become a whimsical, impetuous, post-pub email to the government-mandated virtual surgery, the ‘sufferer’ is sucked into the system, and that system finally becomes unsustainable.
Currently there are fingers in the dam. Let’s keep them there. Otherwise, there will be a symptom flood, which isn’t great when we’re drowning already. And that post-surgery debrief is going to need something a bit stronger than caffeine.
Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs here