… How to be a GP.  Part 1: Diagnosis.

The World Health Organisation suggests there are over 10,000 human diseases.  And one of a GP’s main jobs is to decide which one of these the patient has come in with (though often it’s equally valuable to rule out which of the really nasty ones it isn’t).

And so begins the dance of history taking.  As a medical student we’re taught a list of yes/no questions to ask which takes about a million years to complete.  With a little more experience you refine this algorithm to take in likelihood of different conditions, narrowing down the field one question at a time. 

It’s a bit like playing the board game “Guess Who?” but with an enormous board of ten thousand characters.

“Do you affect men and women equally?”

“Do you mainly affect kids or old people?”

“Do you cause unsightly and painful pustular boils in your skin creases?”

“Are you hidradenitis suppurativa?”

There’s another statistic which suggests that of the patients a GP sees, two thirds of them have (however horrible they may be at the time) minor and self-limiting conditions. Of the remaining third, half have a long term condition that will never go away, and the remaining patients have a significant condition that will benefit from treatment.

The problem is they don’t come in in that order.

How much easier would my morning surgery be if it ran like this:

bit of a cold

bit of a cold

bit of a cold

bit of a cold


Dengue River Fever!

repeated two or three times?

Could patients maybe consider meeting up in advance and arrange so you arrive in this order?  We have a patient participation group where you could perhaps sort this out?  I’d really appreciate it.

9:00-9:40 trivia
9:40-9:50 chronic disease
9:50-10:00 concentrating and on top of my game.

But as we’ve said before, with 10,000+ recognisable diseases it’s pretty tricky to stay on top of everything which is why we have specialists.  The guy who was best man at my wedding is a hip surgeon.  His brother is a knee surgeon.  Their skill levels and satisfaction ratings are through the roof.  Twenty five years ago when I trained, hips and knees would both have been done by the same orthopaedic surgeon.  A hundred years ago by a general surgeon.  Five hundred years ago by a barber who happened to own an axe.  This advance in specialisation is definitely a Good Thing. 

But specialist doctors don’t have to make diagnostic decisions in the same way as us.  Often when GPs refer patients we know the diagnosis already.  If I send you to a knee clinic I can be pretty sure from a history who has arthritis and who’s had an injury. 

When I worked in hospitals as a urologist, the GP had generally done the heavy lifting diagnostically by narrowing it down at least to a single speciality, often a single condition.  In obstetrics this was less taxing as often the clues were more obvious.  

Also, and I learned this in casualty, a patient in a twinset and M&S slacks looks much weller than the same patient in her hospital nightie.

Even so, some specialists hold their diagnostic cards pretty close to their chest until a biochemist or radiologist writes down the diagnosis and hands it to them on a piece of paper.  Yes, neurologists! Everybody’s clever when you have a normal MRI report in your hand

So surely there’s a better way. 

Like we said, there are about 10,000 known human diseases.  And about twenty-seven thousand NHS GPs.  So perhaps if we split up into groups of two or three and take one condition each (bags not backache or COVID) we’ll all be expert diagnosticians in no time.

And then all we super-specialised GPs will need is an intermediate tier of tweed-clad doctors in swivel chairs who can sift through to try and find the needle in a haystack (or often the needle from in amongst an enormous stack of very similar needles) and ensure it gets to the right place.

I wonder what we’ll call them?

GP: It’s most probably a virus

Consultant: But it could be a heart attack!

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