Monday, 14 April 2008


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.


Fiona said...

Forgive me, I am not medically trained, but surely warning bells should have sounded for this nurse upon taking Deborah's history and discovering she had had cancer in the past? Or, at the very least, warning bells should have sounded at some point before 3 months had passed?
As someone who is being treated for depression I see my GP on average once a month for my repeat prescription: I have never seen a nurse for it and nor would I ever want to.

Jobbing Doctor said...

One of the essential skills of general practice is the art of diagnosis. If you had read the London Observer over the weekend, this is the kind of problem that Professor Richards was referring to. Poor history taking would include doing a formal depression score, such as a PHQ-9, and being very aware of the past medical history. Also, if somebody does not respond to treatment, then you need to question the validity of the original diagnosis.
This is a good example of why you need skilled diagnosticians in primary care. Its what we do.

Made by Mandy said...

This is pants.

Granted somebody showing depressive signs needs that to be looked into but body and mind are megally interconnected.

And a GP should check a person's medical see if any serious physical problems or diseases have been present prior to treating anything as if it were purely a MH issue.

I feel for Deborah..more than I can write. What time is left for her, I hope she is given ample support and comfort to live it to the best quality it can be for her.

As for the GP. I wonder what they are thinking about this right now...or if they are thinking about this right now because they ruddy well should be. It's too late to go back and change things for Deborah but it shouldn't happen again.

Made by Mandy said...

Think I misread the post.

So Deborah didn't even see the GP. That is worse. In that it was left to the nurse to treat her.

Yep, I think the nurse should have checked the medical records and talked with the GP before doing anything.

Isn't checking people's medical records the norm in the health service?

Dragonfly said...

I agree with Mandy. Although depression et al are rampant and we have to have a high index of suspicion for them....this is a case of people being overkeen to prescribe what seems like a quick fix. I guess that sad cases like this occur no matter what, but it does seem quite preventable (well, as you said, not that this lady would have had a better outcome, but it could have been managed much better).

Calavera said...

My goodness, that's a shocking story.

Although, I do feel for the nurse. It's not her fault. She's not trained to pick this sort of thing up, she's not trained to diagnose. She was simply doing the best job she could try to do.

I don't understand why Deborah didn't take herself to a GP instead?

Fiona Marcella said...

One or two things in this story bother me (OK it's supposed to bother me and of course it's a terribly sad tale) but even so... Shrink, have I got this wrong. I thought you were a specialist in older age psychiatry so what was this nurse doing referring a 40 something year old to you? Also, from the way you describe her, it would seem that the nurse was a psychiatric specialist nurse. Was the GP just relieved to have palmed yet another psychiatric patient off on her so that he didn't have to bother with her himself? Surely he should have been monitoring her physical health himself especially given her prior history. Does he regularly assume that because a patient's diabetes is being excellently managed by a specialist diabetic nurse he doesn't have to bother about his asthma?

Hospital Wallpaper said...

A sad story. Unfortunately for Deborah, it shows exactly why doctors are needed. It disturbs me that the nurse in question carried on the treatment for 3 months without questioning the diagnosis or seeking a second opinion from the GP.

The Shrink said...

Fi you've got it in a nutshell, that's my point . . .

. . . at an extreme polarisation, nurses can do some diagnosis but most are inherently so patient centred they believe and work with what patients tell them. Doctors are inherently so illness centred they believe and work with symptoms and signs.

Jobbing doctor, exactly.

Mandy, checking records is routine yes, the nurse had the information but got lost in the symptoms and misery Deborah had rather than focussing sufficiently on illnesses. Deborah realised she felt unwell. She realised her health needed checking up. She realised she was out of sorts and it wasn't normal for her. She realised this therefore needed a professional to work with her on it. She realised it was more than advice from NHS Direct and instead contacted her GP surgery. She realised she needed an appointment and to be seen and needed help. Where she came unstuck is that she wasn't offered a GP appointment, she spoke to recpeptionists (I don't think it's a nurse doing triage but I could be wrong) and was given a nurse appointment. She realised she couldn't tell a GP surgery how to it should run it's practice and accepted what was proffered. She didn't realise that the nurse was weaker at timely diagnosis than the GP. Ho hum.

Dragonfly, I do feel she was cheated, yes.

Cal, I actually agree with you, ghastly though it is, it's not the nurse's fault. She's simply in a role that she shouldn't be in, undertaking diagnostic work. When she gets it wrong, exactly as when medics get it wrong, morbidity and death follow. Much badness.

Marcella, my agreed Job Plan is rather complex. Yes, I'm trained as a GP then as an old age psychiatrist, but I've also exertise in other areas that means I've been tasked with other roles. Sadly the nurse wasn't a psychiatric specialist. She is a practice nurse who prescribes. She sees many folk with depression because depression's common, but equally she's told me she sees lots of people to syringe wax from their ears!

HW 3 months of autonomous practice without clinical discussion or review when working outside core competencies is, indeed, scary.

Vicky Pollard said...

This story illustrates precisely my problem with the whole 'nurse practitioner' idea - nurses trained in one narrow area of practice, such as prescribing for mental illness, do not get the overall view of the patient that would have allowed her (the nurse) to see that Debbie's symptoms may have been due to mets.

Made by Mandy said...

Hi again Shrink

So what we have actually is a case of Receptionists, initially, deciding what is best for patients.

Oh Dear!

I don't mind delegation when the person has the skills and understanding to be delegated to but receptionists and nurses are not and should never be a replacement for GPs.

Am not dissing nurses here just trying to look at defining lines and there really need to be some.

Unknown said...

I haven't made up my mind yet whether I think nurses being able to prescribe is desirable.. this sort of story would push me to say no!

Anonymous said...

Picking up on Mandy's point; aren't we talking about Receptionsts triaging being a little out of scope? Or is it routine for nursing triage at first appointment?
I understand when I go to the GP with symptoms X, Y & Z I will get screened with tests A, B & C or possibly a dose of medicine A, B or X, (usually broad spectrum). I can see the advantage to nurse prescriber doing this standardised monkey work - but surely somewhere in that 6 weeks a medical review would have been sensible.
It's not just the treatment we're auditing - it's the whole change of practise.

And diagnosing and treating depression has always been a stretch for GPs so how is it that NPs in GP surgeries are going to do this any better?

As for diagnosis - anyone can argue that nurse ought have picked up this or that but the bottom line is - I prefer medics to diagnose and then I have an objective framework to work within.

However, since I work in mental health, I still find many psychiatric diagnoses are full of shite and are merely slapping labels on one or two "symptoms" - which are more often a means to an end that is not treatment related but assists them in some moral determination they've made about the individual.
Hmm.. that felt good

dutchdoctor said...

In my Trust patients are being screened by non-medics. They decide who will be seen by a doctor. I expect that patients at least would be discussed with a consultant, but that is not the case. This patient might have got the same treatment at our secondary service. But what can I do?

The Shrink said...

I'm in agreement that mental health diagnoses have oft times bene labels for symptoims or behaviour, not a robust diagnosis. But not if I can have a say in it - I'm keen to say people are not psychiatrically ill especially if there's psychological or emotional distress (rather than psychiatric illness).

Dr Xerxes I find that unacceptable. I have a look at every referral. Every afternoon I meet with the CMHT and discuss every patient everyone has seen. I've tried otherwise. But if I don't, it's not sufficiently multidisciplinary care and patient care suffers.