Risky business: the challenge of being a GP

Serious illnesses often start with everyday symptoms. David Haslam, Chair of NICE, explains how this is a complex challenge faced by GPs.

David Haslam, Chair of NICE

I will never forget those words. A few years ago I was talking to the President of the Royal College of Surgeons about something or other – quite probably cricket – when out of the blue he said, “I just don’t know how you GPs do it”. I was puzzled. “Do what?”, I said. “Face all that risk every day,” he replied. “I couldn’t cope with that. I need things to be much more straightforward.”

Ask ten thousand people which they think is the riskiest task - surgery or general practice - and the only ones who will answer “general practice” will be surgeons or GPs. To the vast majority of the population, the drama of surgery looks horrifically risky. I’ve just been reading Henry Marsh’s wonderful book on his life as a neurosurgeon – “Do no harm” – and his sweat-inducing descriptions of clamping an aneurysm deep inside the brain are beautifully written, and clearly packed with risk. How can an average day in an average general practice possibly compete for adrenaline?

But the challenge facing GPs is a really complex one. Most serious diseases start with common symptoms. In retrospect, it will be all too clear that the niggly headache was the first sign of the brain tumour that was eventually diagnosed. But niggly headaches are common. You might have had one today. I certainly did. And the vast majority of niggly headaches are caused by relatively harmless conditions like stress, or anxiety, or a cold, or sinusitis, or nothing-very-much-at-all.

So faced with someone with a niggly headache, does a good GP arrange a scan? Almost certainly not. And if you are wondering whether it wouldn’t be just safer to scan everyone “just to be sure” and even suspect that I am just trying to save the NHS money, the answer is still – no. After all, there is always a significant risk that the scan will find something – something absolutely irrelevant, utterly safe, but that can’t be ignored once it is known about. This could be something like an entirely trivial and very minor aneurysm that will never rupture or cause damage – but once you know it exists becomes very difficult to ignore – difficult for both the doctor, and especially the patient. Hippocrates said it –“First do no harm”.

So the task of general practice – of recognising when symptoms absolutely do need to be taken very seriously – remains an extraordinarily tricky one. And it is therefore gratifying that NICE is updating its guidance on the diagnosis of cancer. As the NICE website says:

Signs of cancer may also not be clear or obvious and GPs see, on average, only around eight new cases a year. A full time GP will have between 6,000-8,000 appointments every year. And they will only have around 10 minutes per appointment to pick out warning signs that could be cancer, but equally may be a symptom of a less serious condition.

You can see exactly why that esteemed surgeon understood the challenge of working in primary care. The drama may not be as great as it is for those who skillfully wield a scalpel whilst working medical and surgical miracles. But a life that is saved by early diagnosis is just as much a life as one that is rescued from a life-threatening event.

And we all have very different skills. As my wife often comments on seeing my DIY skills – “Thank goodness that you never became a surgeon”. How true. How very true…