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A tale of two diagnoses

‘And another thing, doctor…’

We have used nine minutes and forty-five seconds of our duty doc ten minute consultation discussing the shortfalls in healthcare solutions to chronic low back pain.

‘Dr Smith said I should get this checked in a couple of weeks,’ indicating a lump behind the angle of her jaw. On examination there was one of those firm lumps, not mobile and not tender, which make your diagnostic antennae stand to attention and send the message CANCER UNTIL PROVEN OTHERWISE to your frontal lobes.

My patient is in her late fifties, a current smoker, bit of a cough, bit hoarse from time to time, too. Clinical suspicion moves into red zone. She’s quite calm when I explain about two-week rule referrals to exclude suspected cancer and that she will be seen urgently in a combined head and neck clinic with ENT, maxillo-facial and oncology consultants.

I suspect she will turn out to be the next victim of the epidemic of head and neck cancers that has reversed the steady decline in what was previously a smoking related illness in older men with high alcohol intake. The upsurge in cases in a younger, healthier population is almost wholly attributable to human papilloma virus (HPV) infection.

I complete the referral pro-forma on line, send it off, type the notes and continue the duty doc surgery prefacing each consultation with a: ‘Sorry to have kept you waiting so long.’

A couple of hours later I meet my final patient: a woman in her early thirties about to get married and horrified to discover she has genital warts. I had spoken to her on the phone earlier in the day and offered a range of consultation options in response to her request simply for a prescription for medication to treat the condition. Her emotional angst was enough to justify an urgent appointment and she for one did not mind waiting in the duty doc waiting room melee. We discussed her condition, its implications and origins and proceeded to a clinical examination. The diagnosis was confirmed and treatment prescribed. We had further discussion about the sensitive issues which any sexually transmitted infection raises. What she hadn’t known was that the same virus that caused her warts may well cause cervical cancer in the future - good old human papilloma virus again.

What this duty doc was thinking was that the application of evidence based public health policy would consign both of these patient consultations to the history books. (i.e. eliminate HPV and this head and neck cancer and her genital warts would no longer occur). We have an immunisation campaign, admittedly for girls only, but worldwide we are seeing fantastic results - Australia has already seen a fall in genital wart infection rate of 90% and concomitant improvements in cervical cancer screening. Based on this success the campaign there is now open to boys, too.

Back in the bunker of the duty doc, my role in this - to help reduce the burden of ill health on my patients - is to fly the flag for simple immunisation and vaccination programmes. If you think that’s a battle already won remember that more than 40% of parents in America don’t want their children immunised against HPV!  

Dr Peter Weaving is the GP-clinical director for North Cumbria University Hospitals Trust and a GP partner in Carlisle. @PeterWeaving.