Skins

I grow weary of the knocking copy directed against GPs that appears on a daily basis in the newspapers and from the BBC. Today, it is a report from the dermatologists. I can’t be bothered to go through it in detail – I do not wield the knife myself – but do take a look at the response from the Jobbing Doctor who does do surgery.

The BBC reports:

A separate study of skin cancer biopsies sent by GPs to a London teaching hospital showed that 14% of the tumours involved were "high risk", and should have been referred straight to a hospital specialist.

In Norfolk, analysis of the records of 80 patients with melanoma found that 13% of them had been incompletely excised or biopsied in primary care

I do not doubt it is true. To digress for a second, I note with distaste that the currently fashionable but distinctly odd linguistic affection of describing that which should be plural as singular is spreading.

Think about the above figures a little. You could have said:

86% of tumours removed by GPs were not high risk
87% of melanomas were completely excised by GPs

That sounds good, but the media would never put it like that. Instead, the Times' headline is "GPs skin cancer operations could prove fatal". Let me tell you something else. Dermatologists do not have a much better clinical diagnostic success rate. They biopsy everything. And if the answer comes back as  “melanoma”, it is not the dermatologist who does the wide excision, it is the plastic surgeon.

Doctors tend to categorise skin lesions as 

1. obviously cancer
   
2. probably cancer
   
3. may be cancer
   
4. probably not cancer
   
5. not cancer. 
   

It is amazing how often a lesion which is clinically not cancerous turns out to be so when the pathologist has taken a look. Medicine is about judgement. If Dr David Shuttleworth wants all skin lesions to be referred to dermatologists under the “two week rule” that is fine by me. The system will break down immediately and no one will get anything biopsied for months.

There is something else this article does not tell you; something else that the arrogant Dr Shuttleworth does not tell you either; something that the PCTs are quietly implementing; something that the government is trying to hush up

Hospitals are financed by a fixed payment (tariff) for each patient that is seen or each operation that is performed. If your GP refers you to hospital, his or her Primary Care Trust (PCT), which is the body which contracts on behalf of the GPs, will be billed by the hospital when you are seen.

How these changes may affect you

Most Primary Care Trusts (PCTs) are trying to save money and reduce hospital bills by asking GPs to refer fewer patients to specialists working in hospitals. Many PCTs are setting up ‘intermediate services’ that are not covered by the Choose & Book system outlined above and which they perceive to be cheaper. Patients referred to these services will not be offered choice, nor are they likely to be seen by a fully trained and accredited dermatologist on the GMC (General Medical Council) specialist register. You may be seen by a GP with a special interest in dermatology and perhaps a dermatology diploma, a doctor trained elsewhere in Europe or perhaps a specialist nurse. Some, but not all, of the individuals working in intermediate services may also work closely with a consultant dermatologist in the local hospital department. (British Association of Dermatologists)

I don't see why we need the snotty remark about European medical training but leaving that aside it is clear that even when you are referred to a Consultant you may well end up being seen by a non-medically qualified nurse-quacktitioner or the nearly as ludicrous GPwSI. What’s the difference between a doctor and a nurse? Five years at medical school. What's the difference between a GP and a GPwSI? Arrogance.