100 Cases in General Practice

This book is the third book in the series I’m reading. It was much worse than the first two I read – I gave it two stars on goodreads, but I was significantly closer to one star than three.

In a way the format of this book is quite different from the format of the other books I’ve read so far, in the sense that pure management aspects, follow-up procedures, communication aspects and similar stuff play a much larger role. It’s still 100 cases and 100 answers, but the ‘how to deal with patients’ aspect of medicine played a much larger role in this book than it did in the ‘previous ones’ (I believe they were written later, but…), whereas e.g. aspects like diagnostics were not emphasized to nearly the same extent, though many cases do deal with such things as well. It probably makes a lot of sense to focus on stuff like that, given that this is a book written for GPs who probably spend a lot of time dealing with patients, including patients with which they build a relationship over time, compared to some other types of doctors. One downside is that I personally am much less interested in such stuff than I am in ‘the other stuff’. Some cases were in a way only marginally related to medicine at all; for example there’s a case where a doctor observes a colleague smoking cannabis after his shift has ended (‘how would you best deal with such a situation?’-type answer), and a case where a patient is offering gifts to his doctor, again with a ‘how should you handle that situation?’-angle (apparently gift-giving from patients to doctors is a quite common phenomenon: “Most doctors are given between one and five gifts per year and the most common items are chocolate and alcoholic beverages or other food items”).

None of the cases in the book are ‘real cases’, they state this explicitly in the preface; rather the cases have been written in order for the book to present common themes encountered in general practice. Some of the cases simply made me annoyed and that’s part of why the rating is not higher. One made me outright angry because it was obvious that not only was it made up, the details also served to make it clear that the authors are [redacted]. Setting: A statistician presents in the clinic and demands a medically unnecessary cervical smear. Here’s one key passage from the answer part:

“The GP is talking about the patient’s absolute risk of developing cervical cancer. He noticed the absence of all risk factors and the previous normal test results. The point at which low risk becomes medium or high risk is based on scientific evidence and expert opinion. The patient talks about relative risk. Relative risks can sound quite dramatic when used outside their context and doubling of risk can sound very worrying. The doctor’s role is to communicate risk in context.”

The patient is supposedly a statistician. It gets even better, they lecture on in the answer part and tell us that:

“Any screening programme aims to maximize benefits and minimize harm and cost. Through statistical modelling, experts have worked out that it is safe to offer cervical smears at certain intervals. Patients at risk, for example those with mild dyskaryosis, are offered more frequent testing. Possibly, more frequent testing for all is likely cause harm: women will be inconvenienced having to take time out to undergo the tests; the number of false positive tests will increase proportionally with the number of tests conducted, resulting in unnecessary fear and investigations; and the money spent doing these test will not be available to provide other services”

Again – the patient is a statistician. This is the sort of thing statisticians tell doctors, not the other way around. This case isn’t just implausible, it defies belief – this sure as hell is not how an encounter between a statistician and a doctor would go down. It almost made me laugh, after I’d cooled down and stopped wanting to hit the authors. It makes sense to include a case or two where a patient is confident he or she knows better than the doctor what’s wrong/what’s to be done/etc. and where the doctor knows that the patient is wrong and ill-informed, because I’m sure that happens all the time in general practice, but when writing a case like that at least give a moment’s thought as to how plausible the case is. You really don’t want the illustrating example in your book to be one where a doctor lectures a statistician about statistics – if you do you just end up looking like a [redacted].

Other great moments in the book that could be mentioned would be a case about a Somali asylum seeker who’s lived in the UK for 6 years yet somehow is still in need of a translator due to not having learned to speak English yet, and a case where some parents are asking their doctor how best to go about mutilating their newborn child (“it would be reasonable to advise the parents to contact the authorities at the local synagogue or mosque for a list of approved and trained circumcisers”).

Not all cases are bad – for example there was a rather interesting one about the family of a terminal patient, where the family basically demanded that the GP kill the patient (“The oldest son approaches the GP: ‘You can clearly see that my father is suffering. We want you to give my father more morphine to stop him breathing. If you don’t do it, I will speed up the syringe driver and say you did it’.”). Not an easy situation to handle, to put it mildly, and situations like these probably do occur occasionally. However while there’s certainly some good stuff in the book and quite a few cases which will teach you something you didn’t know about the kind of stuff a doctor working as a GP may have to deal with on a regular basis, this is still by far the weakest of the publications in this series I’ve read – I have in part for that reason decided not to quote extensively from the book in this post. I was actually considering not blogging the book at all, but it seemed to make sense to at least talk a little bit about it here; now I have.