Diagnosis, getting it right

Contact’s Medical Adviser, Dr Martin English writes... 

As a doctor getting the diagnosis right is a challenge. If you manage to identify something that has puzzled your colleagues it is gratifying, particularly if you can then sort the problem out for the patient. At other times you wish you weren’t right, when the diagnosis means that the patient will have unpleasant treatment or the outlook is not good. It is impossible to be always right. As a paediatric oncologist the new patients I see have usually been filtered at least twice before referral to me so it ismore likely than not that they will have some form of cancer. But not always. My undergraduate lecture on childhood cancer includes a chest X-ray of TB in a patient whom I saw. Fortunately it was recognised at an early stage, but it is possible that we might have done lots more investigations before we realised what was going on. I also recall a case where we thought a patient had a TB-like illness, but in fact did have a cancer. It took a while for the penny to drop.

Going through the process of diagnosis is not easy for families. Things are taken out of your hands and you are left helpless waiting to be told what is going on. Delays can be very frustrating for both doctor and family and sometimes it is tempting to make snap judgements. The more experienced I get the more I try to resist this as it is always harder on families if you have to go back and change what you said previously.

“Going through the process of diagnosis is not easy for families. Things are taken out of your hands and you are left helpless waiting to be told what is going on.”

Over the years we should have seen improvements not just in how diagnosis is done, but in how it is communicated. We have introduced multidisciplinary teams of doctors, nurses and other professionals to make sure that we make a diagnosis promptly, safely and correctly for all patients and to ensure that we communicate the process of diagnosis, the actual diagnosis and the treatment effectively to families. I have mentioned the National Institute for Clinical Excellence Guidance for Standards for Children and Young people with cancer before. Measures have now been produced from this guidance (stretching to 190 pages!) and all the paediatric oncology units and shared care centres need to comply with these. Much effort is going in across the country to confirm that units are compliant with the guidance. This year units will be expected to upload evidence of their compliance with the measures. Next year there will be inspections of children’s cancer units in England to see if they meet the measures. The inspection teams will need to include representatives of users, i.e. families and patients. We would appreciate your help if you are approached about this. We need our patients and families to tell us what does and doesn’t work. This has kept many paediatric oncology teams busy since last year.