So I’m seething. The news that Jeremy Hunt is proposing to name & shame GPs with a poor record in spotting signs of cancer has propelled me back to blogdom. However I’m trying to write this while my 8 month old is chewing my knees, and repeatedly trying to commit harakiri by hurling herself from a precarious standing position onto the stone floor in a desperate attention-grabbing move, so I apologise if I sound distracted.
No one wants to miss cancer. It’s what keeps us up at night. i’ve lost count of the times that I wake up at 3am and lie there driving myself crazy over whether I should have sent a young girl with what felt like a benign breast lump, that came and went with her periods, for a mammogram, over a year ago. Its our biggest fear. Did we miss something? As a result of that, could we have compromised our patient’s health? Shortened their lives? It’s the fear that makes me doubt my career choice. It’s the fear that drives me to read BMJ articles at 4am when my daughter has just finished mangling my nipple and I can’t get back to sleep. If we let it, it’s the fear can get out of hand and become all consuming.
So why don’t I refer everyone I see who has had a cough for three weeks for a chest x-ray. Actually, forget chest x-rays. They’re terrible at seeing early cancers. Why don’t I send them for a chest CT? Why don’t I send everyone who has lumpy boobs for mammograms? Everyone with a mole to the dermatologist? Keep my own conscience at bay? Stop it banging on the door to my consciousness at 3am?
Where do I start? Both time & money are finite resources, and it is our job to use them as carefully as we can. If I send everyone with constipation to see a gastroenterologist then waiting times will increase. People who actually have bowel cancer will fall down mile-long waiting lists, and by the the time they get seen, it may be too late for them. If I irradiate every person with a persistent cough for a chest CT, i will unnecessarily dose them with radiation, and may well end up causing more cancers than I was trying to prevent. I’d love to refer everyone. I can’t tell you what a relief to be to hand over the responsibility. To check that everyone in my care is safe by scanning them, or sending them for an expert opinion. But the system would collapse. Specialist clinics would cave in under the weight of demand. And I would be blamed.
But maybe this is what the government wants. The healthcare budget is the biggest chunk of money the government have to find every year. The largest slice of the money that they collect in taxes. And with an ageing population, who are surviving longer, with more illness, that figure is only set to rise. And the only option is to charge more taxes, and no government that wants to retain their grasp on power is going to send out that message to their hard-pressed voters. But if they break the NHS, and lay the blame at the doors of GPs? Then they can sell bits of it off to the private sector, get more support for its eventual privatisation. And they’ll show their hands, free of stain, and say “It wasn’t us. We were trying to help.”
The other thing is that spotting cancer can be hard. It’s been learning how to disguise itself for thousands of years, and it’s got very good at it. It doesn’t wave a flag with a big red “C” on it. And we don’t have Star Trek machines that we can hover over your temple and give us a read out. So we do the best we can. We follow guidelines, use our clinical judgement, use our gut. But we’re human. We have 8 minutes to see a patient, hear their story, examine the bits that worry them, decide the next step, explain, make the phone calls, book the necessary test, reassure, and check the patient understands. And sometimes, despite doing everything in the way we are supposed to, we’ll still miss something. And the thought that if that happens, our names could be displayed in a big register of bad doctors, causing our patients to doubt us, and our confidence, careers and lives to collapse, fills me with even more fear.
So what will I do to prevent that happening? I will refer, refer, refer. People will get unnecessary doses of radiation, the unnecessary worry of waiting for a result, people will be seen in overfull clinics by over-worked registrars. The system will bulge, and burst. And the government will wave their hands in glee that they have been given the excuse to relieve the country of the burden of the NHS.
The answer isn’t naming and shaming. The answer is more GPs. More training. More support. An ultimately, I’m sorry to say, more taxes.
And in the meantime I’ll continue to wake up at 3am and worry about your bowel problems. Because that’s my job.
PS I wanted to write loads more, but have stopped for fear of losing your attention. Oh and all these are my own views/ ill-considered knee jerk reaction. And I’ll probably change my mind.