It’s a day late, I know, I know, I’m sorry – (It will be worth it, promise!) I haven’t been well in the last few weeks, I completely forgot all about Saturday Submissions last week and then I do it a day late this week, oh dear! I can do better than this, surely!!
This week I speak to Dr. Liam Farrell, yes, a real doctor, or at least used to be a family GP, now better known as an award winning columnist and broadcaster. You can find Liam over on Twitter as @drlfarrell.
Why presentations are best served rare
We are doctors; we do terrible things to people. They come into the surgery like healthy folk and go out as patients. If they’re really unlucky we confine them to an institution where the occupants are routinely left immobile, deprived of sleep, fed a diet that is tasteless and nutritionally marginal, and experience the de-humanizing indignity of being half-naked all the time.
The average age of a patient in general practice is 75 years old.. Many have multiple diagnoses, and their care is incredibly complex, and above all requires more of our time. But our time is in increasingly short supply, so much of it wasted on the worried well and on health promotion. If we reckon on 15 mins per consultation, a family doctor with 2500 patients would spend 7.4 hours per day to deliver all recommended preventive care and 10.6 hrs per day to deliver all recommended chronic care.
This leaves a generous 6 hours every day for those pesky acutely ill patients, sick certs, insurance and passport and DLA forms, paperwork, eating, sleeping, banging our heads against the wall in sheer frustration, toileting and reproducing. But what is never understood, by patients, the general public, the media, bureaucrats, managers or politicians, is the huge numbers of people family doctors see who aren’t sick, and who have nothing wrong with them; this really can’t be comprehended unless you sit in with a family doctor for a whole surgery. A huge part of our job is telling people what they don’t have. Unfortunately, ‘nothing wrong with you’ is a retrospective diagnosis and can only be made after the consultation.
As the threshold for attending healthcare services grows ever lower, there are more and more worried well, too much screening and over-treatment. It becomes harder and harder to pick out the really sick person from amongst the ranks of the worried well; when you are looking for a needle in a haystack, the last thing you need is more hay. There is consequently not enough time and resources to the really sick; so everyone loses, especially those with hard to recognise rare diseases.
As The Fat Man said in The House of God, when a medical student hears hoof-beats outside a window, he thinks it’s a zebra.
Which might be true, of course, in certain circumstances – if you were in practice in the Serengeti, for example (curiously, I was once in the Serengeti, heard hoof-beats outside my window, peered through the early morning mist and saw only an old cow).
A medical axiom used to be that common things are common and uncommon presentations of common diseases are more common than common presentations of uncommon diseases. But this is now known to be misleading. Taken all together, rare diseases, and rare variants of common diseases, are not uncommon. And diagnosing rare diseases is very difficult; it’s not as if there is a are disease specialist we can refer patients to.
I do have some hard-earned experience. As an intern, I saw a young lad in casualty. He had fainted at a disco (yes, it was that long ago, Saturday Night Fever was quite fashionable. Old age is creeping up on me, not sure why but fairly sure it’s up to no good) and he had a few unusual skin lesions and a labile BP.
These days, I doubt if I would be able to recognise a phaeochromocytoma ( a rare tumour of the adrenal glands) if one walked up and assaulted me with a blunt speculum (I’ve been flogged into apathy by too many URTIs and sick certs, rare and interesting diseases only present to other doctors), but I was young then, fresh and sharp and so hip, I could hardly see over my pelvis.
I wrote ‘possible neurofibromatosis?’, ‘possible phaeo?’ on the chart and admitted the young man to the ward. I was too green to realise the importance of hoarding unusual cases to myself, for my own advancement, and sure enough, the rumour spread around the hospital as fast as an epidemic of flaming gonorrhoea.
Later, when I went to check up on my patient, I found him buried under a tide of medical students, SHOs and research registrars, all keen for a piece of the glory, all ordering 24-hour urines, all dreaming of a case report for the peer-reviewed journals and another notch on their CVs.
‘Help me, doc,’ he said, desperately, ‘they’re suffocating me.’ I whipped away the students, but the others were far above me in the hierarchy and I could offer little succour.
‘Sorry, pal,’ I said. ‘It’s a common complication of uncommon diseases.’
Thank you so very much to Liam for providing todays Saturday Submissions!
What did you think of his post?
Do you relate as a medical Zebra?
Please leave a comment and let Liam know what you think, be sure to check out his Twitter Link and make a new connection!
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