Here is Nye Bevan, forever credited with the creation of the NHS, opening a health centre in 1954: ‘… there were three elements that went into the making of [the health service] — namely, the patient, the doctor and society — and that these were not always on good terms with one another. Doctors sometimes gave the impression that they thought the other two were there in order to attend upon them. Patients took a slightly grudging attitude to both. Society, represented by the central government and the local authority, had the obligation of providing the apparatus the doctor wished to use for his patients. The doctor was never satisfied that the apparatus was good enough for its purpose, and the central government or local authority was often satisfied that the doctor might not be good enough for the apparatus. … A general practitioner’, Mr Bevan continued, ‘did not necessarily receive sufficient intellectual refreshment.’1 It is easy to feel that things don't change much for doctors and patients, that helping patients in the privacy of the consulting room is the same as it has been for generations. But it's hard to imagine any government minister (or ex-minister) describing the relationship in such terms 50 years on.
Now, for instance, we have the eminently sensible 2-week rule for those with suspected cancer. The verdict on upper gastrointestinal cancer might be ‘useful’: current guidelines are likely to identify 72% of those later confirmed with cancer (page 611), leaving the 28% with vaguer symptoms. For colorectal cancer (page 608) the picture is less optimistic, with the guidelines having little influence. Partly, referrers are ignoring the guidelines (nothing new there, then), but for colorectal cancer many subsequently confirmed cases fall outside the guidelines. A qualitative study on page 584 explores the rule's impact on patients and practitioners. It should help the patients' fears as they await the specialist consultations, but the specialists worry about the effect on the waiting time for those falling outside the guidelines, and the general practitioners about missing the diagnosis. So they should, when it comes to prostate cancer (page 617), where the literature gives no help in identifying any symptoms that will identify early cancer, or distinguish between benign hypertrophy and cancer. Hence the plea for screening, of course, but the controversy on that will continue for some time yet, as Theophrastus intimates on page 635. It's easier when the most frequent presenting clinical features point so clearly towards major pathology, as with testicular cancer (page 595). Then again, diagnostic difficulty is not confined to serious physical illness. Psychological diagnosis is dissected on page 580. The general practitioners studied still tended not to give as much weight to somatic or social symptoms as to psychological ones. The editorial on page 570 puts some of this into a theoretical context. No one should ever forget why diagnosing serious illness is genuinely more difficult in primary care.
We all worry about making mistakes. It's mostly the desire to do the job well, mixed with professional pride, what Amanda Howe encapsulates in the wonderful phrase ‘How I might be/(For them and for the rest)/The best of me (page 644). When things go wrong we may have to deal with the agonies of patients’ complaints, but the account on page 636 is a candid account of the positive learning that can come out of the conciliation process. Neville Goodman finds editors of medical journals wanting in their ability to keep clichés out of the text. (page 647) We are not included in the criticism, but it's impossible to imagine that there aren't any. How about a competition (usual prize) to the reader spotting the most clichés in this issue of the BJGP? But the worst error is failing to appreciate how good and easy our lives are. For a smart corrective, turn to the wholly dispassionate account of medical care in Burundi on page 634.
Enough intellectual refreshment for one month?
- © British Journal of General Practice, 2004.