The future of diagnosis in general practice

William Hamilton

doi:10.3399/bjgp20X710777

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The future of diagnosis in general practice
William Hamilton

Published on: 15 July 2020
The future of diagnosis in general practice
John PG Bolton

Published on: 13 July 2020
Point-of-care testing
Louisa Polak

Published on: 03 July 2020

Published on: (15 July 2020)

The future of diagnosis in general practice
William Hamilton, Professor of primary care diagnostics, University of Exeter
I thank Drs Polak and Bolton for their comments. I agree with Dr Polak that point-of-care testing shouldn't replace the age-old primary care skills of using time to help with diagnosis - and management. That explains my lukewarm support for them, in giving only one example (inflammatory markers), and then writing they are not as good as generally thought.

Dr Bolton is concerned about my use of language in conflating anxiety and anxiety disorder. Of course anxiety (as a lived experience) is common and not necessarily disease, though I thought that distinction was clear in the piece. Nonetheless, he has a very valid point - the medical terminology in this area is sloppy. My particular bete noire is 'stress,' which is used as both a cause of ill health and as a 'diagnosis'. In my A-level physics, I was taught stress was a cause, and any resultant change was named 'strain'. Couldn't medicine adopt this, or are pedants like Dr Bolton and myself doomed to fail?

As to 'triage', I'm happier my meaning was clear, and correct. Words evolve, and my Chambers Dictionary offers me a definition for triage of 'allocation of resources to where they will have the most effect'. Sifting patients into high risk (do more tests) and low risk (reassure) seems to match that.

Competing Interests: None declared.
Published on: (13 July 2020)

The future of diagnosis in general practice
John PG Bolton, Retired military GP and Public Health Physician, None
I am worried that Professor Hamilton, a professor of primary care diagnosis feels that anxiety is a clinical diagnosis. It is not. Anxiety is a normal emotion that we all experience and is not found in the International Classification of Disease. The illness in which anxiety is a feature if it is present to a psychopathological disease is anxiety disorder. I make this point because we as a profession seem to be colluding in an attempt to regard every psychological aberration as a disease process rather than a variant of normality and we then go and prescribe excessively to sort this out whilst society loses any resilience it had.

I would also like to challenge his use of the word triage which is increasingly misused. Triage comes from the French verb trier meaning to sieve or sort. It has evolved from military conflict dating back to the Napoleonic Wars and the American Civil War and is defined as "Sorting casualties and the assignment of treatment and transfer priorities to wounded at each echelon of medical care".¹ That is a far cry from the use of the word in the Journal of recent issues including Professor Hamilton's article.

Reference

1. Roberts P, Editor, The British Military Surgery Pocket Book. 2004. British Army Publication.

Competing Interests: None declared.
Published on: (3 July 2020)

Point-of-care testing
Louisa Polak, GP, Guildhall and Barrow Surgery, Suffolk
I welcome Professor Hamilton’s¹ reminders that much primary care diagnosis does not involve testing, and that increased testing may produce harms as well as benefits. But I feel he conflates three different ways in which testing is “available to the primary care clinician”: rapid point-of-care tests are a subset of the tests that may be available in-house, which in turn are a subset of the tests the primary care clinician can request. It is this last, outermost set that matters most to clinicians and patients. In-house testing is not a clinical issue, except insofar as it may increase the amount of testing we do; it is often convenient for patients, particularly in rural areas, and imaging is an enjoyable sideline for many clinicians, perhaps aiding retention. Point-of-care testing is the issue I want to comment on.

As a GP, the only point-of-care tests that I want to do within a 10-minute consultation are those which inform decisions I need to take by the end of that consultation. CRP testing may fit the bill, as Phillips et al’s findings² in this issue of BJGP suggest. But for most other tests, immediate results are of limited benefit in the context of current practice in UK primary care. My goal in the first 10-minute encounter with a patient is to establish an agreed account of their problem and make a shared plan about what to do next. If that plan includes tests, it also...
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I welcome Professor Hamilton’s¹ reminders that much primary care diagnosis does not involve testing, and that increased testing may produce harms as well as benefits. But I feel he conflates three different ways in which testing is “available to the primary care clinician”: rapid point-of-care tests are a subset of the tests that may be available in-house, which in turn are a subset of the tests the primary care clinician can request. It is this last, outermost set that matters most to clinicians and patients. In-house testing is not a clinical issue, except insofar as it may increase the amount of testing we do; it is often convenient for patients, particularly in rural areas, and imaging is an enjoyable sideline for many clinicians, perhaps aiding retention. Point-of-care testing is the issue I want to comment on.

As a GP, the only point-of-care tests that I want to do within a 10-minute consultation are those which inform decisions I need to take by the end of that consultation. CRP testing may fit the bill, as Phillips et al’s findings² in this issue of BJGP suggest. But for most other tests, immediate results are of limited benefit in the context of current practice in UK primary care. My goal in the first 10-minute encounter with a patient is to establish an agreed account of their problem and make a shared plan about what to do next. If that plan includes tests, it also includes a plan about responding to the results, often involving (at least) another 10-minute conversation, before which I have the opportunity to think about the result and what it means for this individual. Meanwhile, the patient has the opportunity to think about what we said the first time, sometimes discuss it with others, and come back with new points to raise. Accelerating this process would damage it.

References

1. Hamilton, W. The future of diagnosis in general practice. Br J Gen Pract 2020; 70 (696): 319-320. DOI: https://doi.org/10.3399/bjgp20X710777.

2. Phillips R, Stanton H, Singh-Mehta A et al. C-reactive protein-guided antibiotic prescribing for COPD exacerbations: a qualitative evaluation. Br J Gen Pract 2020; 70 (696): e505-e513. DOI: https://doi.org/10.3399/bjgp20X709865.

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Competing Interests: None declared.