THE BLOG

Three Strikes and You're In

06/08/2015 00:12 BST | Updated 03/08/2016 10:59 BST

Last week's, seemingly weekly, blockbuster headline on just how useless GPs are announced that almost a quarter have to see their family doctor at least three times before the idiot finally cottons on to the fact that they have cancer and refers them on for further investigations. Not surprisingly 39% of those i.e. 5000 out of the 60000 patients with cancer assessed in the study where somewhat miffed by this. I'm only surprised that the figure was so small. But maybe I shouldn't be because maybe, just maybe the others with delayed diagnoses recognised that picking up their cancer was not as easy a task as it seems when represented in bald print. Maybe they recognised that cancer can present in a myriad of subtle ways. Are those forgiving patients giving their doctor an easy ride or should they be beating a path to their nearest lawyer?

Let me give you an example of a patient presenting to their doctor with a common symptom, say that of shortness of breath. There are over 60 potential causes of this bread and butter GP consultation ranging from asthma to vocal cord dysfunction. Some are incredibly common such as: asthma, COPD, chest infections, angina, heart failure, anaemia, anxiety, panic attacks and prescribed drugs whilst others are blindingly rare such as: myasthaenia gravis, aortic dissection and diphtheria. In the GP surgery, lung cancer is very much towards the rare end of this spectrum.

So how does a GP arrive at a diagnosis? Well, for a starter, he or she rarely does so on the first appointment unless the patient attends with additional features that even a primary-school first-aider would spot. If someone comes into my room and proceeds to vomit blood all over my computer than even I tend to think that something sinister is going on here. The way we actually tend to work is to ask a lot of questions, examine the patient, continuously put forward hypotheses based on our findings and gradually strike these off until we are left with a list of working diagnoses based on the maxim that 'common things are common'. In other words we deal with the most likely scenario and modify our opinion when that diagnosis is tested and found to be wanting. This method of working cannot be undertaken over one consultation. I'm actually surprised that if often takes place in less than three visits and our GPs should be recognised for when this does happen.

Over the 40 years that I have been a doctor I have noticed that 'textbook' presentations of disease are becoming rarer. For example we have all come across stories of the healthiest of people succumbing to heart attacks whilst on the squash court. The same applies to cancer. It has tended to become a more subtle, nuanced adversary and when a doctor misses or delays a diagnosis of cancer he feels that he or she has failed their patient miserably. This is not something that is taken lightly and followed by a night's untroubled sleep. I have met a lot of GPs in my working life and believe me when I say that nobody enters that profession without having a deep seated care for humanity.

The alternative to this 'traditional' method of practicing medicine would be immediate referral of any suspicious symptoms such as breathlessness to secondary care for further investigations such as chest X-ray (not as helpful as you might think) or CT scan (much better). The cost, of course, would bankrupt the NHS and overwhelm the service to the benefit of the very few and the detriment of many.

So please, please forgive us if you might have had to see your GP a few times before you were referred to hospital for anything.

However what can not be forgiven is another feature of cancer care measured in the report published in the European Journal of Cancer Care; that is the insensitive manner in which the doctor managed their diagnosis. For a profession that deals predominantly in people we can at times be remarkably ignorant of how to do so.