This edition of the BJGP has cancer as its theme and contains several important clinical messages on the subject. Many articles, however, also deal with some of the generic, central tasks of general practice — our core business — including diagnosis and risk communication.
The imperative to make an early, accurate clinical diagnosis whenever possible still strikes me as an unarguable aim in any consultation with a patient who has come seeking an explanation and help for symptoms that they either cannot understand, or cope with, or both. Yet even this is still controversial, and some argue for the diagnostic use of time as an efficient way of allowing symptoms to evolve before potentially unnecessary investigation and referral, which seems about as sensible as standing on a railway platform without a timetable hoping that a train will come along soon.
I’m all for maximising diagnostic accuracy and for focusing more effort on developing digital decision aids which, when well-integrated into natural workflows, must have the potential to reduce some of the well-recognised decision making slips that lead to misdiagnosis and delay, such as: failure to gather appropriate information; failure to process information correctly; ignoring disconfirming evidence; and forgetting to consider all diagnostic possibilities. Chima and colleagues report that although electronic clinical decision support tools have been shown to improve practitioner performance and diagnostic accuracy in simulated patients for a range of conditions, many factors have hindered their implementation in primary care. It’s probably more appropriate to concentrate on this aspect of the ‘digital doctor’ than on providing smartphone alternatives to GPs.
Another crucial aspect of diagnosis is safety netting — putting in place clear arrangements to make sure that when symptom interpretation is uncertain or the progress of a condition is not known, patients know exactly how and when to seek further attention. Almost exactly 10 years ago we published an article called ‘Diagnostic safety-netting’, which set out pretty much exactly how to do it.1 In two papers in this month’s Journal, Peter Edwards and colleagues have described how safety netting is currently being used and have developed a coding system to ensure that the arrangements made for safety netting are clear and well-documented and communicated to patients. In another paper, Alice Tompson and colleagues found that, although most GPs like the idea of safety netting, current guidelines on its implementation may be difficult to implement in full because of constraints of time and workload.
Two interesting studies from Jon Emery’s group in Melbourne, Australia, examine the ways in which patients make different decisions about treatment preferences depending on the ways in which risk is presented to them. They looked at the differences between using a simple government statement of benefit and three decision aids depicting risk in different graphical ways. One of the studies was on women’s willingness to take selective oestrogen receptor modulating drugs to reduce breast cancer risk, and the other on people over the age of 50’s willingness to take aspirin to prevent colorectal cancer. Their findings are likely to be transferable to other settings where risk needs to be communicated either differently or in more than one format to maximise information transfer. One example is the doctor–patient discussion about treatment options for prostate cancer, elegantly dissected by Sam Merriel and Vincent Gnanapragasam in their editorial, which also introduces a new online resource called Predict Prostate (https://prostate.predict.nhs.uk), which provides personalised information regarding prognosis and the adverse effects of treatment.
This issue of the BJGP should arrive in time for Christmas. When you’ve caught up with all your CPD and appraisal requirements, I hope you’ll look at some of the other sections of the Journal and meander through its various delights, including some interesting thoughts about Dostoevsky and Gauguin in Life & Times, two stimulating Debate & Analysis articles on the essence of general practice, and a sprinkling of book reviews, opinion pieces, and viewpoints. A very Merry Christmas to all our readers.
- © British Journal of General Practice 2019
