Mrs B was a 35-year-old housewife with two children. She was well-known at her GP surgery since childhood and had needed support with a troubled past.
She had suffered abuse as a child and domestic violence in her first marriage. She attended the surgery very frequently with anxiety issues and lots of minor ailments. She would have a list of things that she wanted to discuss each time she attended and consultations would frequently take a long time.
Some years ago, Mrs B had been referred to the breast clinic and was diagnosed with fibrocystic disease. Mrs B mentioned several times on her way out of the doctor’s room of having sore and lumpy breasts.
Several of the GPs she had seen had documented this as part of her lengthy consultations and she was examined several times. This, however, always seemed to be part of a “by-the-way” mention rather than a full and detailed examination.
Mrs B felt anxious about her breasts and continued to report this when she saw her GP about other things. Dr T knew Mrs B well and found her to be a challenging patient. He struggled to be able to separate her physical and psychological issues, which were often intertwined. Mrs B always seemed very emotional about her personal problems and Dr T knew he would always run late after he had seen her. He found her increasing breast discomfort was difficult to assess.
Dr T had wanted to give fuller attention to Mrs B’s breast symptoms and had asked her to return on another day for a new assessment, but she had failed to attend. Dr T’s partners also saw Mrs B many times with multiple symptoms and issues. A breast examination had been documented several times by different GPs and always mentioned lumpy breast tissue. Fibrocystic breast disease was mentioned on each occasion.
After 12 months she was eventually referred to breast clinic with her persistent symptoms. She was diagnosed with breast cancer. Unfortunately, her disease was quite advanced and she needed a mastectomy and chemotherapy.
Mrs B made a claim against the doctors at her surgery for the delayed diagnosis. The case was settled for a moderate sum.
- Fibrocystic breast disease is a diagnosis of exclusion. If symptoms persist the diagnosis needs to be challenged on a regular basis. The initial diagnosis could have been wrong or it may have evolved into something else.
- Continuity of care is important, especially in reviewing the nature of a breast lump over time. This can be difficult in busy surgeries with many GPs but it is good practice to ensure that it is the same doctor each time in order to make the comparison objective. As more healthcare professionals are involved in a patient’s care, comprehensive notes and good communication are important.
- NICE has published guidance on Improving Outcomes in Breast Cancer (28 August 2002). It has a useful section on managing breast lumps which GPs should be familiar with. The document makes several recommendations, some of which are outlined below:
- All patients with possible or suspected breast cancer should be referred to a breast clinic without delay.
- Urgent referral (within two weeks) should be arranged for:
- Patients aged 30 or over with a discrete lump in the breast
- Patients with breast signs or symptoms which are highly suggestive of cancer. These include ulceration, skin nodules, skin distortion, nipple eczema, recent nipple retraction or distortion (<3 months) or unilateral nipple discharge which stains clothes.
- Breast lumps in the following patients or of the following types should be referred but not necessarily urgently:
- Discrete lump in a younger woman (<30 years)
- Asymmetrical nodularity that persists at review after menstruation
- Persistently refilling or recurrent cyst.
- Beware of “by-the-way” mentions from patients on their way out of the surgery. Sometimes they hide serious pathology. If there is no time for a full assessment, arrange a new, later appointment.
- Challenging patients may require particular care. Patients with complex psychological, social and psychiatric needs can, and often do, have physical problems. There is an interesting article about challenging patients in Casebook (May 2009). It has some insightful case reports and tips on management.
- Patients that don’t attend their appointments raise several issues. Where does the doctor’s responsibility end? What should GPs do about it? It may be useful to have a practice meeting to discuss this and consider developing some practice guidelines about safety netting for “did not attend” patients.