I had a busy day in the practice yesterday. I arrived at 8am, I left at 8.15pm knackered and limped home too tired to talk to my family. I worked flat out, and yet I only ‘saw’ two patients all day. To be honest, I didn’t find it very satisfying. I was laying hands not on patients but on a computer keyboard, dispatching prescriptions for painful abdomens that in the past I would have felt.
Of course, I was talking to people all day on the phone and computer screen and was busy ordering tests, prescribing, making referrals etc. But I didn’t feel that I was connecting with and assessing people with the same depth as when I see people face to face.
Does that now officially make me a dinosaur? Possibly, but I’d like to argue not. As my friends and family will testify, I love a gadget. I’m an early adopter of new technology (I’d rather not contemplate how much money I’ve ploughed into the Apple empire over the years). But I became a doctor, and especially a GP, because I want that personal contact and communication with patients, to use my hard-learned diagnostic skills, to help patients through the difficulties that life and illness throw at them. Of course, you can do all of that on the phone or via a video call and anyway it’s not about me and my job satisfaction, it’s about what’s best for the patient. I just think you can’t do it as well and that it may be particularly problematic for symptomatic, vulnerable patients.
As we nervously skate along the long green piste of the tail of the pandemic curve we find ourselves on thin ice. The collateral damage is starting to emerge across all three of the bio-psycho-social domains of health and illness. For us in primary care, there are massive challenges in how we help our patients with long term conditions, mental health problems and with diagnosis of new disease especially cancer.
Back in May, my colleague Kate discussed the post-covid cancer time bomb. Since then we have had data published on the ‘brutal impact’ BMJ2020;369:m2386 of the pandemic on urgent cancer referrals and this week it has been widely reported in the media that the pandemic could result in up to 35,000 excess cancer deaths in the UK. There are many reasons for this, including patients’ reluctance to come forward and the suspension of screening and secondary care services.
However, a drop in diagnosis of cancer in primary care may be a vital contributory factor. If a patient calls us with a clear red flag (breast lump, rectal bleeding, haematuria…) then it’s easy. We act. But most patients present with vague symptoms (fatigue, low grade pain, some weight loss, a bit of nausea…) often dismissed by the patient as trivial and easy to ignore on a telephone or video call. Remote consulting has some evidence to support it as safe; but we have seen a whole system change of seismic proportions built on pragmatism, to protect patients and staff from covid-19, rather than a solid evidence base.
So, I am seriously worried that remote consulting may contribute to the cancer crisis through missed diagnoses, as we miss out on the vital cues and clues that we pick up when seeing people face to face. These clues and the unspoken energy in the room are crucial to our diagnostic ‘sixth sense’ or gut feel. Every GP has experience of thinking ‘something is going on here’ that the patient has not expressed, and that line of thought ends up in a diagnosis. We save many lives this way. General practice has always been about managing uncertainty, but remote consulting just adds another level to it.
Another major concern is that remote consulting favours the digitally savvy from higher socioeconomic groups whom, as Tudor Hart famously taught us with the inverse care law, are more likely to call on our resources despite having less need. During all my calls yesterday I was struck by how many were young, educated, and working age. I work in a city centre practice and I feel we are having less contact with the elderly, the housebound, the homeless, and those from minority ethnic groups and I fear that this will compound further pre-existing cancer-related inequalities in referral and outcomes.
Remote consulting became a necessity to protect patients and staff from coronavirus. But I believe we need to be very mindful of how it may contribute to the cancer crisis, and that we need to lower our thresholds for seeing patients face to face especially from vulnerable and disadvantaged groups.