Saturday, 30 June 2007


I have written before about the advantages that IT gives me as a doctor. There have been two further examples this week.

My friend Martha sent an internal email to all the partners asking if any of us knew whether patients have to stop taking warfarin before they have cataract surgery. I entered the words “warfarin cataract surgery” into Google, and the second item in the list was a link to an article in the BMJ from January 2004 which reviews evidence and concludes that it is not necessary to stop warfarin (or aspirin). I emailed the information back to Martha, but simply quoted the study and did not reveal how I knew about it. Martha (bless her) wondered at first whether I had remembered reading the article three years ago. That raised an interesting question, because although I have no recollection of reading the article I did have a vague idea that it is not necessary to stop warfarin before cataract surgery. It is certainly true that GPs know a lot of things but cannot always remember where they learned them. Our “hunches” are probably based on a lot of half-remembered facts sloshing around in our subconscious. But of course we need to check our facts before advising our patients, which is where IT can be so helpful.

The second example was a woman in her mid-fifties, who is in pretty good health and keeps herself to herself so we don't see her that often. She came to see me a few weeks ago complaining of pain at the bottom of her back, and tiredness. She was tender over her sacrum, so I arranged an X-ray of her pelvis and the routine “tiredness” bloods. These were all normal except that the full blood count showed her neutrophil (white cell) count was a bit low. This is something that can happen temporarily following a viral infection, and I didn't pay it too much attention. At our second consultation she mentioned that her weight had gone down slowly over the previous three years. I realised that she did look a bit thin and off-colour, and on weighing her I found that she has lost nearly a fifth of her weight ten years ago (the last measurement recorded in her notes). I was getting a bit concerned at this point, but I could not find any clues to go on. She had given up smoking two decades ago and had no cough, so lung cancer seemed unlikely. Her bowels were normal, she had seen no blood in her stool and her recent blood tests showed that she had not become anaemic, so bowel cancer seemed unlikely. In any case, cancer usually becomes obvious within three years. Her recent blood tests also showed that she did not have diabetes (normal blood sugar) or an over-active thyroid. In addition her ESR was normal, this is a non-specific test that indicates inflammatory processes that might have been responsible for her weight loss. I could find no clues on examining her: there was no muscle wasting, none of her lymph nodes felt enlarged, her chest was clear, there were no lumps in her breasts or abdomen. She still felt tired and had the low back pain. I was puzzled (and wrote this in her notes) and I asked her to go for a chest X-ray. This was partly because I thought it might show something, and it is certainly an important investigation to get done when investigating weight loss (cancer, tuberculosis), but it was also to give me time to think. I often find when I am puzzled that things become clearer when I see the patient again a few days later. I don't know why this is: it may be that it is easier to understand the story when you hear it the second time, or it may be because my subconscious has been doing some thinking in the meantime.

The hunch I was waiting for duly arrived when I saw her again this week. She was feeling better and the chest X-ray was normal, but I ferreted through her records and noted that her neutrophil count had been normal in the past but has been slightly low on several occasions since 2005. So the story was now weight loss plus consistent slight fall in neutrophil count over three years. And suddenly my subconscious said to me “do you think this could be myeloma?” I had thought that myeloma was an illness of old people, but I turned to the ever-helpful GPnotebook which told me that the average age of onset is 60 (so mid-fifties is perfectly possible) and that weight loss is common. It also reminded me that it may cause bone pain. The diagnosis is not certain, because her ESR was normal, the pelvic X-ray did not show the classic “lytic” spots, and the white cell count is usually normal according to GPnotebook. But I remember one of my mentors saying that if you wait for a full set of symptoms and signs before you make a diagnosis then you will never make it. So I have arranged some more tests specifically looking for myeloma (immunoglobulins, urine for Bence Jones protein, calcium) and whatever the results I shall be referring her to a haematologist.

The colossal amount of information available on the internet does not make GPs redundant. Our skill is separating the wheat from the chaff, of finding the relevant information and knowing how to apply it. As an analogy, there is a vast quantity of information about current events available on the internet. There are also a number of websites giving interpretations that are sometimes eccentric, to put it kindly. What we need are journalists that we can trust, who will sift this information, interpret it and tell us how it relates to us. You can think of your GP as your local friendly neighbourhood health journalist, if you like. At your service.


The Shrink said...

Our “hunches” are probably based on a lot of half-remembered facts sloshing around in our subconscious.

Our skill is separating the wheat from the chaff

As I've mentioned a couple of times this week, I see a GPs core business as sifting through the plethora of symptoms they're presented with, and ascribe significance to this.

Only GPs really have and hone this skill.

Although capable diagnosticians, feeling a "hunch" or finding "soft signs" or having a "high index of suspicion" and referring on appropriately to Secondary Care, it's GPs that do this mental sifting of wheat from chaff.

By the time someone gets to Secondary Care they've no longer got numerous complaints or symptoms that you've had to tease out, they've got a History (written by you and reproduced by the patient with what they felt you felt was important). Too, the medics seeing them in Secondary Care will be seeing a far higher proportion of folk with significant pathology and don't have the same rigor of the wheat/chaff process you exercise.

Oddly, as a student this never came across.

It was only through supervision in my VTS days when discussing managing uncertainty that this penny dropped, with the epiphany that GP land was all about the GP having what you refer to as half remembered facts (a broad and active recollection of relevant facts) combined with the ability to sift through material patients generate then apportion significance to this, then marry the two (medical facts and clinical significance) to generate a meaningful conclusion.

Dr Andrew Brown said...

Ah, you make it sound so easy!

(And it is, on a good day, hem hem!)