Are FP/GPs and specialists still two solitudes?

Diagnosis is the key area of the conflict. Those with the most initials after their names usually win the blame game

By Joshua Karpati

Family doctors face pressures from two constituencies. They not only have to focus their attention on patients, but they must also be sensitive to their relations with specialists. The potential for conflict is always present, and the issue of missed diagnosis is a prominent concern. Mention the most-feared spectre of all -- cancer -- and the debate over roles and responsibilities grows tense.

"We primary-care physicians always get blamed," says Dr Michael Dworkind, associate professor of Family Medicine at McGill University. "We do our best to follow screening procedures, but that's only part of the larger picture." Lower back pain, Dr Dworkind points out, is the fourth most common reason for visiting a doctor; and it's almost impossible to pick up renal cancer presenting only as back pain in an elderly patient with chronic discomfort. He notes that looking for a dire diagnosis is often imprudent: "Sore throat and fatigue usually indicate mono, not cancer," he says.

Montreal family physician Dr Howard Mitnick, agrees. "We're talking about case-finding, and in family medicine, it's about playing the odds. A patient can walk in during the winter with symptoms clearly showing the flu. If the same patient comes in the summer, the diagnosis would be very different." Dr Mitnick stresses the value of history taking, particularly using family history as a warning sign: "We're taught to look for indicators, red flags. We're not magicians. It comes with experience." (For more, see The Art of History on page 14.)

Dr Gerald Batist, Chair of Oncology at McGill, sees the need for specialists to support primary-care doctors with timely information. "There is faster-paced change now, a rapid increase of knowledge about all aspects of cancer, from diagnosis to treatment.

"In Canada," he notes, "we're finally getting to guidelines and recommendations that represent evidence-based consensus. This is where clinical work and the scientific world meet -- in applied research -- and it requires ongoing updating."

Dr Batist believes the relationship between the two solitudes has greatly improved. "We're rediscovering one another. Ten years ago I wrote an article about how collaboration between various specialties could bridge important gaps in research. I received an angry letter from a GP observing that there was no mention of their role. Frankly, he was right. We recognize now that we need each other."

REPUTATIONS ON THE LINE
Dr Dworkind was the author of that letter and he's not so sanguine. He points out that most GPs still need to feel supported by the system, and not worry if every decision later has a potential cost in terms of reputation. Otherwise, he contends, in a time of limited resources, "you risk over-investigating and causing unnecessary stress to patients." Dr Mitnick adds, "Patients need to be made aware of the potential drawbacks of ordering tests without cause." All tests hold a potential for harm, particularly if borderline results lead to progressively more risky and uncomfortable diagnostic procedures. "We must explain clearly that facts change noticeably over time," he points out. "Symptoms found after three months were not necessarily there when the initial presentation was made."

Echoing these concerns, Dr Batist says, "I often find myself explaining to a patient that waiting a few weeks or a month or two generally does not lead to a difference in outcome." Dr Dworkind, who works in the palliative care unit at Montreal's Jewish General Hospital, adds that some patients whose symptoms were initially difficult to interpret can even feel relieved when a definitive cancer diagnosis is made. "Their pain has been validated, and they can no longer be told 'it's all in your head.'"

Are patients generally understanding of the pressures doctors face when making a diagnosis? The consensus is that patients' attitudes toward a difficult diagnostic process depends on whether they feel that they have been listened to and treated with respect. For all parties, respect seems to be the bedrock principle upon which common ground is found.