Columnist Dr Copperfield considers why GPs spend more time scrolling through pathology results than they do in consultations
Put that needle and syringe down for a minute, will you, and listen. Where has our current bloodlust for lab tests come from? It’s insane. We have a Pavlovian reflex to print out a fully ticked pathology form before the patient’s got the seat warm.
I say we, and I do mean us GPs, but I mean noctors also, or perhaps especially. Which is why I have slightly strange consultations where I hear myself saying, ‘No, I don’t really know why the ANP checked your CA-125, coeliac screen, B12, vitamin D and caeruloplasmin either. But what I want to know is, is your sore throat any better?’
Well, at last, someone has noticed this, with researchers finding that one in four blood tests done in general practice may be unnecessary. And the rest. Bleeding patients is no longer a phrase of exasperation, it’s what our job has become. True, external forces are at play here. NICE guidance, QOF targets, defensive medicine, the use of a blood form as a get-out-of-consultation-free card now that prescribing an unnecessary antibiotic is bad and so on.
But really: it feels like clicking all the boxes on a path form has completely taken over the diagnostic process. And again, I’m pointing the finger at us all, not just noctors. But mainly noctors.
It’s compounded by the fact that a blood test feeds on itself like a self-harming vampire. A borderline result (and there’s always one) can lead to an indefinite agenda of repeat tests (think: TSH, pre-diabetes, borderline eGFR etc). And one abnormality can trigger an Oppenheimer test-bomb – an elevated ALT locally requires the testing of at least 18 further parameters, with the inevitable fallout meaning the patient feels ill even if they aren’t.
And if you’re not convinced, consider this. We see a lot of iron deficiency anaemia these days, right? Well, what do you expect when you’re bleeding the patient every five minutes? Though their suffering is nothing compared with ours, as we spend more frustrating hours scrolling through pathology results, taken by God knows who for God knows what reason, than we do in consultations.
We should remember the old adage, ‘Treat the patient, not the blood test’. The trouble is, these days, the blood test is the patient. We’re all at fault here. But mostly noctors. Have I mentioned them? I wish they’d bloody stop it.
Dr Copperfield is a GP in Essex. Read more of his blogs here
The art of history taking is now “ancient history” given the way we now practice medicine in the UK. Previously the emphasis was on a history to reach a diagnosis, patients that could articulate a fair history to get to a conclusion within 10 minutes, more simple and single problems, more risk tolerance and appropriate blood taking. What we have now is risk aversion and fear of missing something, complex mutimorbidity / problems with increasingly vague flitting histories from “clients” with poor tarnation spans and it takes a serious effort trying to tease out an adequate history in the 10 minutes we have. Added to that the requirement for a battery of tests before we even open a referral proforma to refer on! Hence the typical consult is now a less than 1 minute history, nil examination followed by a blood battery to be dealt with by the next sucker who will see the patient! And round and round it goes!
so true
its the world we live in sadly
GPs/partners undervalued by lazy dogma driven politicians
Britain is fast approaching a state of emergency the country is almost broke
Tax at a peace time high massive state borrowing billions to pay for unsustainable spending
debt servicing costs highest in G7
New GPC leadership will have its work cut out
I was once told ‘if you listen to the patient long enough, they will give you the diagnosis”
John Graham Munro
I was once told ‘if you listen to the patient long enough, they will give you the diagnosis”
this is still true – what has changed, though, is that very often there IS no diagnosis !
you get a raft of people turning up with all sorts of vague symptoms and drivel that they have seen on daytime tv, wanting to know all sorts of irrelevant rubbish – mostly nothing to do with any illness at all.
i had a very good friend insist on being referred privately to an ent surgeon because she’d read in the paper about someone who’d had a rare tumour (i’d never heard of in 40+ years), and she was adamant she wanted investigating. nothing i could do or say would convince her this was tripe.
it cost her over £1500 for the ent surgeon, scans etc etc etc to tell her it was tripe – and then she wanted a third opinion, because she didn’t believe him “because he looked very young” !!
what can you do with people like that ? !!
David Jenkins.
Quite——-talking to your patient for however long, would lead to NO diagnosis.——-probably dissatisfied because she didn’t have a blood test
Patients report that, according to the NICE website (and I have verified this, and challenged NICE, and they say it is absolutely correct and are not going to change it), EVERY patient with an MCV of 95 or less has Iron Deficiency Anaemia (97%+ sensitivity), and needs further investigation.
So that is another blood test for a full set of iron studies, the elusive ‘cancer test’ that the Government has told patients is available, but forgot to tell our Path Lab about, and a referral to Gastro for both end endoscopy, (plus the required FOB-FIT test first), for the 2/3rds of patients in the middle of the MCV normal range (85-95 fL) plus the 1/6th below 85 fL.
And apparently because they are MCV-wise iron deficient, despite no reference being made to their actual Haematocrit, or Hb level, and no symptoms perhaps.
(yes, I do know thre difference between sensitivity and specificity : sensitivity of the Covid LFD test varies between 6 and 20 % in ordinary people, so it must be guaranteed correct if it is negative, but requires a second opinion if positive).
totally agree with Tony’s findings. It partly explains why all the pleasure is fast disappearing from GP work.
I have been beating this drum (or trying to) for a long time. This article makes some valid points, but unfortunately I can’t share it with my team for discussion and educational purposes, due to the rather derogatory use of the word ‘Noctors.’
‘Noctors’ might include my wonderful ANP team, valued members of our team who work under our supervision and are always learning (as are we all!). They may request more tests than me, and be less adept at knowing what to do with the results, but will get better with time and experience. I would love to share this article with them, as it summarises some of my thoughts/concerns about blood tests better than I can verbalise- but I can’t, as the wording suggests that they are less worthy clinicians.
Get with the times, Copperfield!
LS: really? It’s an irreverant ascerbic blog
I know! But is makes some really good points, better than I can make them, and I wish I could share it with my colleagues.!
L.S.————I’m sure your colleagues would benefit from sharing
The problem is that the ‘old model’ – doctor sees patient, takes history, performs examination, forms list of differential diagnoses, discusses with patient, arranges investigations – cannot be beaten for cost, efficiency and effectiveness.
For some reason, we are moving to a system where the NHS wants patients to be seen by the cheapest member of staff possible (not taking into account on-costs) – and this frequently has very negative clinical and financial consequences that NHSE want to pretend don’t exist.
More insidiously, the finger wagging is always at general practice, whereas as far as I can glean from online path results, the standard protocol in A&E is to do a battery of tests, a chest X ray and at least 1 of some sort of scan; medicine is moving away from the sanctity of history and erudite examination into a “throw the net and see what you dredge up” mentality. Unfortunately general practice – who should really be the epitome of the clinical examination has followed suite and that gels with patient expectation in that they haven’t been dealt with properly until there has been a test or scan “proving” that they are ok.
It’s a perfect feedback loop and the only outcome is a lowering of quality medicine
my ex boss used to say “it’s sixpence for a good one, and fourpence for a crap one – which one would you like ?”
seems to me to represent the thinking of those responsible for running the service !!
Always like reading Copperfield. reminds me of my old senior partner who always said much the same thing, along with “what do you expect at your age?” and “well your problem is you’ve lived too long” was another saying he was well known for. I wonder how long it will be before we enter the age of patients requesting a “whole body MRI” like the Kardashians are advertising in USA? I wonder how long it will be before Amazon supply them? look out!