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Oh no, patient does know best



I’m not going to make any excuses. Well, okay, I am. I was stuck on a train. I had no phone signal. I was there for hours. I had to do something, right? And that was why I was reading the British Journal of General Practice. What? Why was it in my bag? Good question. Unlike everyone else, I can’t sleep on trains. It’s either that or Z-drugs, right, and you don’t get a GMC rap for reading yourself into a coma.

Besides, just occasionally, the BJGP sheds some light on our work. No, really. And I see it as my duty to convey this to you.

Take, for example, the recent article, ‘Chest pain for coronary heart disease in general practice: clinical judgment and a clinical decision rule’. Though I should warn you, this isn’t so much illumination as a super massive black hole about to swallow up one of the great truths of general practice.

One of my fundamental general practice rules states that, whatever patients think they have or need, they haven’t or don’t

The article highlighted the ‘Marburg Heart Score’. This was news to me, and I’m guessing it is to you, too. If not, you’re an even more avid reader of the BJGP than me, so who are you to criticise?

Anyway, the Marburg Heart Score is just one of many scoring tools currently cutting a swathe through good old clinical judgment. Which may be just as well, given what I’m about to tell you. Of the maximum possible score of 5, one whole point is allocated to ‘patient assumes cardiac origin of pain’. Yep. That’s what I said. If the patient thinks the pain is cardiac then, incredibly, it’s more likely that it is.

OMG. This runs a coach and horses through one of my fundamental general practice rules. Admittedly, this rule is based on my experience and attitude rather than a randomised controlled trial, but I don’t care, I know it’s true. Or I did. It states that, whatever patients think they have or need, they haven’t or don’t.

You believe this too, don’t you? For example, patients who say they’re depressed, aren’t. They’re sad/angry/looking for a quick fix to life’s problems/wanting a sickie. Patients who are truly depressed, on the other hand, never say they’re depressed. They say they’re tired, dizzy, can’t sleep, have gone off sex, etc etc.

Want another? Okay, dementia. Any patient who presents worried that they’ve got dementia hasn’t got it. They’ve got stress, depression, anxiety or whatever. Patients who really do have dementia don’t have the insight to realise it or, if they do, are too afraid to confront it. So, patients dragged in by concerned relatives because they’ve been losing it for months and are setting fire to the curtains, yet wonder what all the fuss is about, are demented, whereas patients fretting that they are, aren’t.

If you want, I can give you loads of other examples. Patients who think they’re hypothyroid, bipolar, having a stroke, have MS, have CFS, are diabetic, need an X-ray, need a brain scan, want antibiotics, want a mood stabiliser, will ‘only take a minute’, and so on. They’re not, they haven’t, they don’t and they won’t.

And patients who think their chest pain is cardiac? It isn’t. By definition. But not any more. Marburg has ruined general practice for me. First the virus. Now this.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield