Quite a bit of my job is unchanged. I still see around 20 patients each morning, and around 15 each evening. I still visit people at home, and what I do in that 10 minutes also has changed very little. I listen to a history, examine a patient, and request investigations. I look at these to make a diagnosis, and I recommend treatments, or other investigations, or I do nothing.
Doing nothing is hard. It is so easy to buy yourself time, or wriggle room, by doing things - people seem to expect that. However, this is all about uncertainty. The modern teaching is, when faced with uncertainty, is to do things.
You might start a treatment, for example. We certainly used to do this a lot in the past. When faced with a breathless child, you would try a course of oral steroids. If the child improved dramatically, asthma was the likely diagnosis. This was called the ‘therapeutic trial’.
The therapeutic trial has a basis in history-taking. If faced with chest pain, we often ask if people have tried antacids or over-the-counter medications, to see if they work. That is a useful part of the history. In an era of protocol-driven medicine, this is a helpful way of preventing an individual patient being sucked into rollercoaster medicine as practised in secondary care.
Taking chest pain as an example, if a patient presents to A&E with these symptoms, they are moved onto a conveyor belt of thoughtless decision-making. In an emergency, they get their chest X-rays, ECGs, blood tests (immediate and 12-hour troponins). If any of these are abnormal, then it is off to cardiology and stenting. However, most chest pains are not acute ischaemic events. If the tests are normal, they are usually put on the tramlines of investigations, with a request for perfusion studies, angiography or echocardiography – usually all three.
At no point does the history seem to be revisited. People are swept up on the juggernaut of investigation-based management, and their problems become medicalised as a result. Months and months of waiting and anxiety pass before they determine whether they have a serious and potentially fatal illness or not.
In truth, it may have been better to watch, wait and observe. We do this quite a lot in general practice. I will probably only refer around 10% of chest pain cases. This will improve my diagnostic accuracy, but will also increase my chances of getting it wrong.
Yes, I sometimes get things wrong. Getting something wrong is a huge anxiety for a doctor, and we do not like to do it often. I still beat myself up around decisions made years ago that were a judgment call that I got wrong. If we get things wrong in medicine, then people can get ill and die. That is a responsibility, and one that is not taken lightly. That is the reason that many doctors respond to uncertainty by doing things.
My decision-making changes over time. I do not refer people for vagotomy and pyloroplasty anymore. I do not check acid phosphatase or protein-bound iodine, either – they are redundant.
Some things are the same. I still take a history and do an examination, request tests and I think about what to do. I often do nothing: hard as it may seem, it often turns out for the best.
The Jobbing Doctor is a GP in a deprived urban area of England
