My patient is 26, skinny, and female. ‘I’ve got this pain in my chest, doctor, here at the front.’
‘Costochondritis’, I tell her.
‘It hurts when I breathe in. I went to the urgent care centre last night, but they didn’t know what it was’
‘There were two nurses, and they X-rayed my chest, but that was alright so they sent me to A&E because I had chest pain.’
‘You’ve got costochondritis.’
‘In A&E they did an ECG and blood tests, and a doctor had a look at me – she said it wasn’t my heart, and told me to come here today to find out what is was. What do you think?’
I think you’ve got bastard costochondritis!
It’s impossible to diagnose a condition if you’ve never heard of it, and this is where our underqualified colleagues in urgent care centres tend to fall on their inexperienced and uneducated arses. And, increasingly, our fellow doctors in secondary care are failing to act as a safety net, assuming (a big assumption, admittedly) she actually saw a doctor; the ‘practitioners’ in A&E don’t always tell you if they’re not.
Let‘s face facts: ‘It’s not a heart attack’ is good news (not that my patient thought for a second that it was), but it’s not a diagnosis. Our patients prefer to know what it is, not what it isn’t.
A similar scenario happened with another of my patients last week. She presented to the urgent care centre with barn-door polymyalgia rheumatica, but because it was technically chest pain she was rushed down the A&E pathway, had the ECG, blood tests (but not the relevant one), an X-ray and, for some absurd reason, an ultrasound of her gallbladder. She was discharged with a diagnosis of ‘non-cardiac chest pain’ and told to see a proper doctor urgently the next day, to get a proper diagnosis. Although the discharge letter did not say that in so many words.
I listened, made the diagnosis in 30 seconds, gave her some steroids and the pain went away. I’m not some brilliant clinician. I’m just an ordinary, experienced GP, just like you. Of course I get the odd one wrong. But if either of these patients had seen one of us first, the NHS would have been saved hundreds of pounds in investigations, time and transport costs, and the patients would have been spared an awful lot of needless pissing about.
Maligned, underfunded and undervalued as we are, it is easy to demonstrate that we are cost effective, efficient and, more to the point, usually right – something both those patients were extremely grateful for.
My next patient is a lad with pain in his knee. ‘Here, at the front. It hurts when I play football.’
‘My dad took me to the walk-in centre last night but they didn’t know what it was.’
‘It’s Osgood-Schlatter’s Disease.’
‘The nurse did an X-ray, and there was nothing wrong with it, so they told me to come here to get referred to a knee specialist.’
‘You’ve got Osgoo… oh, never mind. Just take these tablets. And don’t go to the walk-in centre again. It’s not good for your health.’
Dr Phil Peverley is a GP in Sunderland.