NAMED AND SHAMED: GPs who miss cancer diagnoses

If you saw the Mail on Sunday today you would have seen the above headline.

According to Wikiquotes, Daniel Patrick Moynihan, 4-time US senator and academic, once said “You are entitled to your own opinions, but not to your own facts”. Rather than writing an extensive counter-diatribe of rhetoric on the ridiculousness of the article, the irresponsible attitude to health reporting and Jeremy Hunt in general, I have decided to try a new form of discussion. I call it ‘The Facts’.

Fact #1
Here are the National Institute for Clinical Excellence guidelines for referring patients to a specialist with the suspicion of cancer. http://www.nice.org.uk/guidance/CG27*

Fact #2
This is how common bowel cancer is: there are 47.2 new cases per 100,000 people per year (crude). This equals around 40,000 new cases nationally, which means nearly 1 case per UK GP per year.

This is how common breast cancer is: there are 155 new cases per 100,000 people per year (crude)
This is how common lung cancer is: there are 77 new cases per 100,000 people per year (crude)

http://www.cancerresearchuk.org/cancer-info/cancerstats/

Fact #3
The national screening programme for bowel cancer, in the over 60 group, finds cancer in 1.62 people per 1000 people screened.

http://www.patient.co.uk/doctor/screening-for-the-early-detection-of-colorectal-cancer

Fact #4
For bowel cancer: The presentation depends on the site of the cancer: (from Patient.co.uk;)

http://www.patient.co.uk/doctor/colorectal-cancer#ref-4

Fact #5
In a study following 230 patients who presented with abdominal pain, 77% of them were found to have later improved, with no cause for their pain identified. 5 had appendicitis and 1% were found to later have a cancer. [1]
In a similar study following 307 patients presented to A&E with abdominal pain, 88% of them were found to have later improved, with no cause for their pain identified. No cancer was found.

[1] http://www.ncbi.nlm.nih.gov/pubmed?term=7114375
[2] http://www.ncbi.nlm.nih.gov/pubmed?term=8457097

Fact #6
The rate of serious harm in screening colonoscopy is estimated to be 1-2.8 per 1000 which includes bleeding and perforating the bowel wall.

http://www.ncbi.nlm.nih.gov/pubmed?term=18838718

Fact #7
The average GP sees over 10,000 patients per year -

http://www.rcgp.org.uk/news/2014/february/34m-patients-will-fail-to-get-appointment-with-a-gp-in-2014.aspx)

Fact #8
A colonoscopy costs between £1100-£1650 per procedure.

http://www.netdoctor.co.uk/focus/selfpay/costs.htm

The bowel cancer screening programme (for ages 60-69) already costs £77 million pounds per year. http://www.cancerscreening.nhs.uk/bowel/bowel-screening-cost.html

In summary, guidelines exist base on the probability of a diagnosis for further investigation, (Fact 1). Cancer is relatively rare, a single GP will see 1 new case each working year (Fact 2) out of 10,000 consultations, (Fact 7). The presentation of bowel cancer is variable (fact 4), and may be more advanced depending on several factors. Other cancers can be equally vague. Non-specific symptoms are rarely serious, (Fact 5) and returning to the GP is a useful diagnostically. Investigations and diagnosis have their own harms, (Fact 6).

Now for some opinions.

If this new idea comes into practice, GPs will refer more patients unnecessarily. This will mean a greater cost, greater harm without any evidence of benefit. Medicine, sadly, is full of ‘what-ifs’. This article is very willing to discuss what if this patient had been referred earlier to a specialist, but not about what if an additional hundred healthy patients were also referred, the additional cost and the potential harm that might cause. Not to mention the clogging of services.

I’m going to be controversial now. I don’t think lay people should be able to make decisions about health policy. Especially politicians. Health, like so many big topics in our modern society, is incredibly complicated. No one person, doctors included, can fully understand it. That is why we arrange to perform studies by hundreds of people, looking at millions of patients, before we can answer the simplest question in medicine. Politicians need to boil that down to a single-one liner that they can sell to the public and to the newspapers. That is, in my opinion, impossible. And, more than ever these days, incredibly costly, dangerous and irresponsible.

Even more controversially, I don’t think lay people should report or publicise health stories. Most doctors, myself included, struggle to understand what new studies really mean in terms of the patient in front of them. The Daily Mail is one of the worst offenders, it is deliberate and sensationalist and completely unaccountable. I wonder how many patients irresponsible health journalism has harmed? **

Having researched this blog properly, I find the idea that doctors that ‘miss’ cancer being penalised utterly ludicrous. Take the example of bowel cancer- the average GP will only see one new case of bowel cancer a year. So even if he or she ‘misses’ every case they see every year for five years, what sounds like a dangerous and scandalous GP- that’s still only 5 patients out of 50,000. When will Jeremy Hunt decide that GP needs to be named and shamed? How many mistakes would the average person consider acceptable before requiring a GP to be tarred and feathered? 0? 1? 10? 20?

Now there’s an opinion I don’t have any facts for.

juniordoctorblog.wordpress.com

 

*I appreciate NICE guidance as ‘facts’ is somewhat contentions. For those of you are interested their is a lot of controversy about the politicising of NICE, the interpretation of evidence and concerns over ‘tick box’ clinical practice. However, for the purposes of the above, these guidelines exist, and here they are.

** If you are interested, here is how I propose we investigate irresponsible health journalism;  All health stories in major newspapers (Especially the Daily Mail) from the past ten years regarding health topics are identified, scrutinised for their accuracy against the scientific data available, and then calculated how inaccurate they are qualitatively on a scale of 1 to 5, 1 being minor inaccuracies (e.g. misspelling a name) to 5 being major inaccuracies causing potential harm (e.g. reporting an unsubstantiated conclusion and recommending a change in the behaviour of the individual that could result in disease e.g. Avoiding vaccinations). The impact of the story is then calculated by the potential harm, the readership, and the prevalence of the outcome. An excess death figure is calculated based on this. E.g. reporting vaccinations cause autism, calculating the drop in vaccination as per the readership and then the prevalence of new cases of measles for example and excess death. I appreciate this would  be nearly impossible, but this is an exercise in imaginary science. Then, based on this, we could Name and Shame the greatest offenders and the relative risk of reading each paper on the individuals health. By law, this would have to printed on the front of each newspaper under a Health Warning label.

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21 responses to “NAMED AND SHAMED: GPs who miss cancer diagnoses”

  1. Sara Caine says :

    Very well said JD. I’m a GP with over 20 years’ experience and thankfully haven’t missed many serious diagnoses over that time; we all do it occasionally because much as we wish it were otherwise, medicine remains an inexact science and throws us a “curve ball” from time to time. Lay individuals generally (and it seems health ministers and journalists in particular) fail to grasp this fact no matter how often it is pointed out to them.

  2. Sarah says :

    My mum, who is 60, recently visited her doctor to ask if heavy vaginal bleeding -2 years after a hysterectomy- was anything to worry about. She was categorically told yes, perfectly normal, go away. Weeks later, a private gynecologist delivered her diagnosis: advanced (stage 4a) vaginal cancer. It’s certainly rare (approx. 250 new cases per year in the UK), but should mum’s GP have known better?

    Patients are entirely at the mercy of their doctors’ expert discretion. Are we all expected to learn the symptoms of advanced vaginal cancer, just in case? Or are the NHS are willing to reconcile the deaths of 250 women each year? Personally, I’d rather see doctors take rare cancers more seriously, and accountable for their abrupt examinations and flippant dismissals.

    Vaginal bleeding is not expected two years after a hysterectomy, and It doesn’t take 5+ years of medical training to know that unexplained, heavy vaginal bleeding might be something worth investigating.

    • Running with Stethoscopes says :

      Firstly, may I say that I am sorry to hear what happened to your mum. PV bleeding in post-menopausal women is a red flag sign and, from what you have told us, her GP ought to have investigated that.

      That being said, one of the problems with evaluating medicine on a policy level is the emotional punch of a single case where things were not up to par. Everyone can understand how terrible it is to have a relative fall ill, and everyone can grasp how angry and betrayed you would feel if a serious diagnosis is missed. What humans in general are very poor at understanding is information on a statistical level, especially when it is contrasted with a personal story that is easy to relate to. Compounding this effect is the media, which is happy to report on easy scandal but less happy to report on dry scientific papers without a sensationalist angle.

      Vaccinations are an excellent example of this, where the personal tales of people who have found their child (who had the MMR) has autism and this is linked to the vaccine. Despite ironclad statistical evidence that the MMR does not cause autism, these anecdotal data continue to mean that, every year, thousands of children are not safely vaccinated against a triad of dangerous and highly infectious diseases.

      Yes, GPs (and all other humans) make mistakes. Yes, there are bad doctors, try as we might to stop it happening. There are many processes designed to minimise the risks of making a mistake (guidelines, second opinions, extensive training programmes, and retrospectively, complaints) but there will always be errors. Where individual doctors are poor clinicians there are fitness to practice investigations, revalidation meetings, multi-source feedback exercises and competence reviews carried out by other clinicians.

      Doctors who make many mistakes need to be held accountable, but Jeremy Hunts vision of naming and shaming is not a helpful way to do it. Terrorizing good doctors, lumping them in with the bad, is going to drive up investigations in healthy patients and as a result, people will die who did not need to. Yes, in your mum’s case she should have been investigated under a two-week wait and it is appalling that she wasn’t. It doesn’t mean that every patient going to their GP worried about cancer, or even with symptoms that could be cancer (like cough, abdominal pain, headache or feeling tired) should be investigated in a similar fashion, and it certainly doesn’t mean that Jeremy Hunt should be wading in with draconian measures with no evidence that it will benefit patients, and considerable concerns that it will cause them harm.

    • Jim says :

      That’s the problem. Your personal story does not represent the issue. Doctors do take all cancers seriously. Misdiagnosis is a reality. In the perfect world a GP would know everything about everything but that’s not possible. Your comment about it not taking 5 years of medical training to know it might be worth investigating is very easy for you to say in hindsight. You cannot understand every thought process your GP may have been thinking about in that consultation. Doctors are accountable everyday in the good and bad outcomes of their patients. That private gynaecologist that made the diagnosis would have made many mistakes in his or her life as all doctors have.
      You’re right in that patients are at the mercy of a doctors expert discretion and that’s why they took more than 10 years of medical training to be an expert but I’d rather that than my own google searching of symptoms or at the discretion of some politician. And there’s always a second opinion that you can get.

  3. Peter Dilworth says :

    As a retired GP I agree fully with your ideas and proposals.
    Hunt is part of that criminal band of robber barons running the country and should have been sacked / jailed over the BSkyB fiasco. A member of the Bullingdon Club and a PPE graduate at Oxford : a particularly toxic individual. He will have his own sick agenda in relation to this.

  4. D.Kenson says :

    Good points in the article. I must say though that I have had many terrible experiences with the NHS (although not about cancer), and although your argument regarding cancer diagnosis is convincing I wouldn’t put it past the NHS to mess up pretty much anything. I have been treated really bad by NHS staff and the only reason I have never made formal complaints is that, knowing the NHS, it would take years and the process would be more cumbersome than the original offence. I also use private healthcare and have never -not once, ever- had a bad experience there, reception to nurse to gp to specialist. The NHS is just crap, but British people keep defending it. Why? Because, just like with railways, you have not experienced another system and think that ineffiency, delays and general sloppiness is built into the system. It’s not! It’s not the premium you pay fir having public healthcare. Things work much better in other countries…

    • Running with Stethoscopes says :

      Good sir, may I refer you to the recent report stating that the NHS is the best healthcare system in the world. Despite its flaws, which it would be foolish to ignore, it still provides an incredible service, free at point of delivery, to an entire nation. If you read further, it is also the most efficient healthcare system in terms of cost.

      I have two issues with the private sector. Firstly, it is all well and good if you can afford it. If you can’t, and you have no NHS-style service to fall back on, you are toast. A brief Google search will yield you tale after tale of ruined lives brought about by running out of funds for healthcare.

      Secondly, when things go wrong in private healthcare, it is the NHS that has to fix the damage. I have seen many instances of private patients whose surgical complications have ended up with them coming into A&E to have them fixed, for free. Even when things go wrong while a patient is still in private hospital out-of-hours, often patients need transfer to a proper hospital with a full suite of facilities and staff. Ask any doctor where they would rather be if something goes wrong – the carpeted private hospital with no regular overnight on-call teams and a TV with many channels or a busy NHS ward with emergency staff in the building?

      Private healthcare works to a point in that for people who can afford it who only need elective operations or outpatient management it’s fine. Get to the emergency care side of things, or be poor, and see where it gets you.

      • Jeff Smith says :

        Have you read the report in its entirety? It essentially an opinion piece from a think tank in favour of US healthcare reform.

        The survey data are a selection of patient and doctor self reporting questionaries with no information on sample bias or selection methodologies. The questions seem to have cutoffs with arbitrary values and no methodological justification given (e.g. 15 week waiting time for elective surgery good, 17 weeks bad). Categories appear to have been created arbitrarily and combined using a mean rank method with no statistical analysis.

        The paper wouldn’t pass muster an an undergraduate dissertation and if it had been produced saying “NHS bad” you’d all be lining up to rip apart the methodology.

        As for private healthcare, there are many different forms both on the provider and payer side. Canada has a single payer system with almost exclusively private providers, as do many European countries, to suggest its a dichotomy between a “fully” private US system or a “fully” state UK system shows either ignorance or an attempt to be wilfully misleading.

        The problem is that whilst the Government or the Doctors are the only ones to define what good looks like, those patients who fund the NHS (i.e. the generally well, working population) will eventually move to private care and there will begin the downward spiral of NHS provision. This has already happened with Dentistry and eye care, I can see it happening more and more in midwifery/obstetrics and orthopaedics, primary care can’t be far away once someone cracks the charging model. I’d certainly pay £50 to see a GP if it meant I could get an appointment when I wanted rather than taking a day off work to hang around and hope for an appointment or book 4-weeks in advance.

  5. Alix says :

    Well said. While I don’t know so much of the medical side of things, I’m a statistician and am regularly appalled at how figures are reported without any sort of base rate, cancer usually being the main one. As you have pointed out, rates for cancers are very low to start with.

  6. plexity says :

    Reblogged this on arthur battram| and commented:
    We need to bring, as much as we can, this level of surgical precision to management.

    If psychology can be a science, (a claim I find dubious having obtained a degree in it from an excellent college ranked number 3 or 4 in the UK, Hindustani).

    (Hindustani? How could this idiotphone think I meant that when I wrote incidentally? This is why the robots well not take over just yurt)

    As I was saying, if psychology can be a science then so can management.

    There was a brief kerfuffle in the business schools about why they didn’t see the crash coming and why they failed to teach ethics to MBAs. Six months later all forgotten. Gary Wossname would have put on a conference or earned a big fee for meaculpaing, or both. Business school profs make admen look shamefaced and moral.

    I’m not advocating Taylor’s Scientific Management. We have some better science now. And proper true facts are harder to come by in management consultancy. But we could work a lot harder than we do to seek truth amid opinion and cant.

  7. Joanne Taylor says :

    My mum had a spot in the crease at the side of her nose that our doctor tried to freeze off for nearly 2 years but it just kept growing. He never told her what it was or what it could be. When he eventually referred her, when the spot was a lump which was almost the same size as her nose, she was told as soon as she entered the room that it was a rogue ulcer (or basal cell carcinoma). She ended up having almost 1 full cheek removed & rebuilt & she still needs to have 1 nostril rebuilt. She was told by the surgeon that she was lucky it grew downwards inside her face rather than inwards otherwise she could have lost the roof of her mouth as well. Everyone in the medical profession that we’ve seen since have said that rogue ulcers are easy to spot & can be dealt with quickly & painlessly. My mum will have a scar covering half of her face for the rest of her life.
    Try & tell her, and the rest of my family, that doctors who misdiagnose cancer should not be named and shamed!!!

  8. staffscanceradvocacy says :

    Reblogged this on staffscanceradvocacy and commented:
    A compelling response to recent proposals to “name and shame” GPs who miss cancer diagnoses

  9. Dominic Walker says :

    More terrifying than any level of misdiagnosis, is the level of advanced cretinism amongst the Daily Mail readership.

  10. Missy says :

    I’m a doctor. When I visited my GP in order to be referred for investigation of a breast lump, I was given a blood test form with most boxes ticked on it and told to return in a fortnight. I told the GP that I was worried about malignancy and he told me not to worry. I told the GP that I’m a doctor and I don’t like unexplained lumps. He told me that the blood tests would probably reassure me. I told the doctor that my mother had aggressive breast cancer when I was a teenager. He reassured me.
    I subsequently phoned the local breast clinic and found out how to be referred in for evaluation, which was by GP referral alone. I had to return to the GP and persuade him to refer me to the local breast clinic for appropriate evaluation (including an examination, which did not occur with the GP, despite my prompting).
    I’ve had an ultrasound of the lump and I’m probably OK, it didn’t need a biopsy and I’m to return in a few weeks.
    If I’d been a docile patient and listened to the GP, he would have got away with not referring me on this occasion. How many times will he do this until he misses a breast cancer?
    GPs, like any other doctor, must be accountable for their actions. There must be an agreed acceptable level of care. There’s a difference between missing a tumour and not even bothering to examine a patient in order to evaluate a mass in the first place.
    As a doctor, I am permanently paranoid for my patients. It’s a stressful job. I assume the worst case scenario for each patient and work backwards from there,
    I don’t subscribe to false reassurances, at the patient’s expense if I get it wrong.

    Yes, it costs money to investigate a patient, but I’m not denying a patient an investigation due to cost. I am a doctor, not an accountant nor a politician. Let someone else worry about cost. Let me worry about treating my patients.

    • kazimir says :

      this is the mentality that bankrupt the NHS. “I am a doctor, I treat patients, let someone else worry about the cost” – ridiculous statement for a well educated individual. So you probably do CT head on everyone with a headache and CTPA on every chest pain that has no troponin rise?

  11. Dan Haggerty says :

    “Cancer is relatively rare, a single GP will see 1 new case each working year (Fact 2) out of 10,000 consultations”…

    The “Fact 2″ comment only refers to bowel cancer… Not all cancer, which would be much much higher than one per year. Id expect a doctor to be able to work this out. In fact I assume that the author/doctor does know this. Which calls into question their honesty.

    • juniordoctorblog says :

      Apologies I did mean bowel cancer here as the running example.

      • Bob Pilcher says :

        There is no need to apologise. It was obvious that this referred to bowel cancer only. Only someone with an axe to grind would deliberately miss this – or the average Daily Mail reader.

  12. Sarah Adams says :

    How about patients taking some responsibility for their own health, rather than just blindly accepting their GP’s opinions? I had to go back to my GP three times for intermittent pain before I was eventually referred for a scan which diagnosed a rare (and fortunately very curable) form of ovarian cancer. At all appointments I was told I’d probably just ‘strained a muscle’ in that area.

    Should the GPs have realised what was up? Maybe. But the cancer was rare and I was too young (29) for alarm bells to be triggered concerning ovarian cancer.

    I only got the scan which led to my diagnosis by being persistent and not accepting the GPs’ diagnosis. Obvious warning signals like persistent bleeding or intense pain should surely trigger patients to demand investigation rather than just blindly going along with what the doctor says. Your health is in your own hands: don’t pass the buck.

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