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Let's begin with a story. Less than a month ago, an experienced colleague referred an older patient to our local respiratory out-patient department. The history was vague, a 6-month history of malaise and slowly increasing shortness of breath. Six months earlier, investigation including radiography and spirometry had been normal. Our patient was the main carer for a partner with advanced dementia, and life in recent months had been distressing and anxiety-provoking. Examination was unremarkable. However, the patient sounded and looked unwell, and my colleague was uneasy, could there be occult malignancy perhaps? So, more by hunch than anything else the referral was categorised as Urgent. Three days later, with commendable alacrity, a consultant respiratory physician responded with a short letter. The referral did not meet criteria for Urgency and would be downgraded to Routine. An appointment would follow for 8–9 weeks. Another 3 days later, while attending our practice nurse, the patient was noted to be very pale and weak, indeed hardly able to stand. Another colleague saw and admitted immediately. Within 1 week, marked tongue and upper limb fasciculation developed, with difficulty in swallowing and speaking. He was discharged from hospital after a week, for urgent out-patient neurological follow-up. We have initiated domiciliary oxygen. Our patient has rapidly evolving and deteriorating motor neurone disease. There is much for all the doctors involved to ponder in this issue of the BJGP.
Two papers consider ways of improving the safety of primary care: Pearson et al on page 825 examine the role of GPs in suicide deaths; Harnden et al (page 819) likewise in childhood mortality. There are sometimes simple changes that we can implement in day-to-day practice. We should perhaps pay more attention to patients who default from follow-up; or take greater care to follow recommended vaccination schedules; we should embrace systems of confidential enquiry. In an accompanying editorial, Dodds and Fulop (page 805) suggest ‘improving inter-professional communication’. But between which professionals? Those in primary and secondary care might be a required starting point.
And what other simple concept can minimise risk when we make diagnostic mistakes? Safety-netting of course, a term coined by Roger Neighbour over 20 years ago, and examined by Susanna Almond and colleagues in a splendid Back Pages essay on page 872. The Great Man himself supplies an impish coda.
Finally, as this is November, not too early to be thinking of Christmas presents, especially for oneself. Iain Bamforth on page 880 suggests an atlas with a difference, published in 1572. That should do nicely.