Published: 28/10/2004, Volume II4, No. 5929 Page 22
Diagnosis is much more complicated than treatment. It is therefore somewhat naive to seek to address this issue by simply increasing the accessibility and availability of scans or by encouraging near-patient testing ('The Big Story', pages 14-15, 14 October).
Patients need better information on the accuracy of investigations and their costs and consequences.
In a Department of Health press release of 29 June highlighting the expansion in MRI scanning, the accompanying notes stated that MRI scans help 'diagnose. . . acute or chronic migraine and headaches'.
However, headache is the most common symptom presenting to GPs and a large proportion of these seem to have no clear-cut organic explanation. In such circumstances, there is a significant risk that patients receive extensive investigations that are of limited value and are potentially damaging physically and psychologically.
In recent years, GPs have been bombarded with referral guidelines that ignore the primary care context. Secondary care colleagues, who generally write such guidance, rely on their 'specialist experience'.
However, GPs only refer a tiny and highly selected proportion of their patients to these consultants, with the result that such 'specialist experience' often has little direct relevance to the types of patients GPs are likely to encounter on a daily basis.
It would be very unwise to develop guidance on the use of high-technology investigations without the involvement of GPs supported by a primary care-oriented clinical epidemiologist.
In partnership with our patients, GPs like myself accommodate a greater level of diagnostic uncertainty than our specialist colleagues.
Obviously it is always necessary to exclude organic disease when presented with a symptom such as unexplained weight loss, chest pain or palpitations.
However, there is also a need to avoid undertaking investigations beyond those that are absolutely necessary and to recognise that anxiety and depression also present with such symptoms.
Common symptoms are not synonymous with organic disease and neither is primary care medicine merely a faded memory of hospital-based practice. If health service planners continue to ignore such issues, the consequences for patients could be dire.
Dr Nick Summerton GP Head of public health and primary care division Hull University, Medical director Yorkshire Wolds and Coast PCT
Now that we have newer and better diagnostic tests for chest-pain patients, attention is correctly being focused on how clinical biochemistry laboratories can help to reduce hospital stays.
Far from being resistant to change, biochemistry laboratories have led the way in introducing these new tests and in making testing available nearer to the patient. Four points need to be made:
Almost without exception, NHS biochemistry laboratories are available 24/7, at least for a restricted service that would include chest-pain markers (though not all using the latest tests).
France may offer chest-pain markers in the ambulance, but the new markers perform at their best at least 12 hours after the onset of pain and may mislead management of the patient if taken too early.
The potential for avoiding admissions by using laboratory tests for chest-pain patients is difficult to calculate and is often exaggerated. Having looked for such a benefit in my own trust, it is clear that many patients have comorbidity, which means an admission is necessary whatever the result of the markers.
We need better agreement on the appropriate application of diagnostic tests according to the patient's clinical presentation.
There is a perception that laboratories are protectionist about near-patient testing. But those who take on near-patient testing are often unaware of the commitment required to maintain the quality of the service and it is best set up as a joint venture with laboratory staff.
Yet laboratories frequently struggle to resource a time-consuming support role across a large area.
However, when properly established this role does help the laboratory to cope with an ever increasing workload as well as providing a better service for patients.
Dr Brian Senior Consultant clinical biochemist Royal Bolton Hospital
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