I'm drawn back to the issue of diagnosis. Again. Sorry.
I've been referred a lady, let's call her Deborah, from Primary Care. Her mood is a bit low. She's a younger adult, in her early 40's. She 'phoned her GP surgery, complaining of tiredness and feeling drained and unwell, was given an appointment with a nurse there and started on treatment. The nurse (a prescriber) started her on citalopram 20mg once a day. The nurse spent time talking with her, documenting all her symptoms accurately and detailing all her past medical history. The nurse arranged review with Deborah to see how the citalopram was working and to look at supporting her, so saw Deborah again 2 weeks later. Things hadn't changed, so the nurse brought Deborah back again after a further 4 weeks, so she'd tried citalopram 20mg once a day for 6 weeks.
The nurse felt that the citalopram wasn't delivering as well as it should. She's a good nurse, she's attended teaching where I bang on about trying drugs at the right dose for the right duration before saying things ain't working, so after a few weeks she titrated the citalopram up to 40mg once a day. She felt this would help treat depressive and anxious symptoms, helping Deborah relax and helping her cope better. Then, as her hopefully depression lifts, her lethargy and lack of drive and loss of appetite would hopefully improve.
The nurse brought Deborah back after 2 weeks and found that the citalopram 40mg wasn't working well. Deborah was still, "feeling pretty rubbish" so the nurse continued the citalopram 40mg to give it more time to work. After a further 4 weeks, and 2 more reviews by the nurse, she felt that Deborah wasn't getting better. Deborah agreed. Having tried to sort out mild/moderate depression in Primary Care without success the nurse referred her on to me to look at treating this, since she felt it wasn't mild depression.
And she was right.
I saw Deborah and was struck by how languid and lethargic she appeared. She looked ill. The excellent history that the nurse included in the referral detailed past breast cancer with a mastectomy. I scanned her. She's developed metastases in her liver, brain and bone. Much badness. Her loss of energy, lower mood, loss of appetite was due to tumour burden and widespread, advanced cancer. I know Deborah's GP, I know he would have seen Deborah and, given her history of cancer, would have looked at this before referring on. I know this, because over time I've seen this with other patients the GP has.
The delays in Deborah's diagnosis caused by many reviews in Primary Care by the nurse haven't changed the outcome. It amounted to a bit over 3 months of treating her as having functional mental illness rather than diagnosing metastatic cancer. Even if the nurse had referred straight away, it's grim.
Deborah could have had a better understanding of what was going on, though. She could have had better palliation of symptoms. She might have chosen to use her time differently.
The practice nurse, diagnosing and treating, did things differently to the GP. I was reading The Observer yesterday. The front page story had a huge title of, "GPs warned over failure to diagnose cancers." The opening paragraph spoke of, "the government's top cancer expert" and "botched diagnoses." Obviously, GPs must be getting it wrong, no? Well, no. Reading on, the article quotes the experts words as, "'There are 250,000 new patients with cancer every year,' said Richards. 'It's probably only a small proportion who experience a missed or delayed diagnosis. It's a small minority of patients overall."
Curious how this is front page headline news and GPs are botching it up so badly then . . .
. . . like Deborah, I'd still be better served seeing a GP for diagnosis and formulation, despite what the press seem to be saying.