Friday, 8 February 2008

The normal man

I tend to think that private medical screening is a waste of money, but it's easy for me to be relaxed about my health because I have insider knowledge. I know that the odd symptoms I get from time to time (as we all do) don't add up to anything serious. I don't smoke, my BMI is a comfortable 25 (built for comfort not for speed, as my old PE master used to say), I've measured my blood pressure and my cholesterol and calculated my ten year cardiovascular disease risk to be 5%. I'm not smug about my health and I don't take it for granted, but I do know that I have nothing particular to worry about.

So I don't denigrate people who visit BUPA for a check-up to come to the same conclusion. And if you haven't got the money, come and see our practice nurse and she'll do more or less the same thing for free. But there is a problem, which is that the more tests you do the more you are likely to find an abnormality. “The normal man is a very dark horse indeed” said Sigmund Freud, and there is a medical aphorism which says that the normal patient is simply one who has not been sufficiently investigated.

This week I came across an interesting example of this. A patient of mine went for a BUPA check-up, and the examining doctor found a slightly enlarged liver. She must have been extremely thorough because I couldn't feel it myself. This was a bit of a puzzle because my patient was very well and his liver function tests were normal. So BUPA paid for an ultrasound scan which showed a few small nodules in the liver, and the radiologist recommended that my patient should go on to have a CT scan. But BUPA would not pay for this further examination without a GP referral, which was why my patient had come to see me. And he was, as you can imagine, pretty worried by this stage. So much for the reassuring effects of health screening.

If you listen to Government propaganda you will know that your GP is lazy, overpaid, and wickedly reluctant to work on into the night after a gruelling ten-hour day. But he has two other attributes: he has been around the block several times and gained a fair idea of what is serious and what isn't, and he holds your NHS primary care records. My patient told me he thought that he might have had TB when he was very young, and asked if this could have anything to do with it. Looking back through his record I found a letter from the 1950s which did indeed report that his chest X-ray showed enlarged lymph nodes in the centre of his chest, and that he was thought to have had TB but was now cured. The mild abnormalities on his liver scan are consistent with a previous granulomatous illness like TB, and the fact that his liver looks otherwise normal, he feels well and has normal LFTs makes it highly unlikely that there is a serious problem. I am going to arrange for him to see a gastroenterologist to confirm this opinion, but he was much more relieved when he left my consulting room than when he walked in. We are going to try to get BUPA to pay for the gastroenterology consultation, since it was their screening that brought this worrying but incidental finding to light.

I am concerned that some of this crucial information about past medical events, currently stored in those funny little “Lloyd George” envelopes, will be lost when records are finally computerised completely. I have lost count of the times that light has been thrown on an intractable problem by a letter from the distant past hiding in one of the patient's many bulging folders. In an ideal world these letters would all be scanned, filed and cross-referenced against the patient's problems before being shredded but, believe me, the NHS is far from an ideal world.

My last consultation this evening was so delightful I just have to mention it. A little girl had pricked herself quite badly with a sewing pin at school, and her mother had been told by her teacher to get it checked out with the GP. She was a little angel, but clearly very frightened of me and what I might do to her. This was obvious from the moment she walked in, so I immediately put on all my charm and played the reassuring friendly doctor. It was a great pleasure and privilege to reassure her (and her mother) and I reckon it was the best thing I did all week.

Finally, for those of you who don't read the British Medical Journal, there is a lovely tale of a paediatrician with a reputation for being irascible. He reviewed a letter which had been sent to a GP as “dictated but not checked”. A page of detailed assessment ended with “I believe in the end this child will be below normal, like you”. On checking the tape he had actually dictated “I believe in the end this child will be a low normal IQ”. The GP was so used to the paediatrician's eccentricities that he hadn't replied. For my part, I applaud that GP's sanguine lack of response. I know someone not far from here who would have gone puce and dictated a stormy riposte if it had happened to him. I think I may be getting slightly more tolerant of other people's errors and eccentricities, and for me it is one of the few advantages of getting older.

Have a good weekend.


Sara said...

Medical education DOES put a tremendous gap between what you think is serious and what nonmedical people do. I have noticed this time and time again with family members. Totally innocent shoulder pain can send someone into panic, while much more ominous things might not make them bat an eye.

It is part of medical training that you see how well the body is most of the time, and that when something goes really wrong, there are actually a fairly limited number of ways it can show up (the "uh-oh" symptoms). But without that background, it is hard to distinguish. I always wonder when people criticize improper arrivals at the emergency room - sometimes it isn't that someone is wasting resources or too lazy to make a regular appointment with their doctor, but rather that to them, whatever it was that is not that significant could not be distinguished from an emergency.

It has been interesting getting through medical school and then hearing questions asked to me that show me how easy it is to forget that not everyone went to medical school, that things need to be explained, that even educated people do not have a deep medical background.

And good job with the kid!

Anonymous said...

It's terrifying that we may lose paper records altogether. In a few decades time, once all doctors put plenty of information into the computer and the Gp2Gp system is running properly it will probably be ok but for now the paper records contain so much information that never makes it onto the computer (not least because of totally under qualified summarisers like myself) it would be madness to get rid of them.

The Shrink said...

Receptionist, I agree. I like paper.

"In an ideal world these letters would all be scanned, filed and cross-referenced against the patient's problems before being shredded but, believe me, the NHS is far from an ideal world."
We know this won't happen.
At present the NHS has a lot of information to store. At one conference I was told it was five times as much information as the Pentagon own. That's a lot of letters and notes to scan, detail, cross reference and generate in to an accessible and user friendly information system. Realistically, it can't happen.

My one consolation is that in my corner there are so many legal forms, on paper, that have to exist. As such, paper records of one form or another are destined t live on and remain fairly commonplace for me. Phew.

"I think I may be getting slightly more tolerant of other people's errors and eccentricities, and for me it is one of the few advantages of getting older."
I find things that use to pique me or send me incandescent with rage now simply generate mirth. It's got to be a healthier way to amble through life! :-)

Anonymous said...

Once, in one of my former identities, I was given the task of transcribing tapes because one of the surgeons dictated in French. You can get a measure of his desperation by the fact that I really can't type in the secretarial sense, so taking literally hours to do them.
One of his earlier letters had instructions on how to get to the hotel do van. I wish I could remember more of them.