Authors’ reply to TaylorBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h433 (Published 28 January 2015) Cite this as: BMJ 2015;350:h433
- Georgios Lyratzopoulos, clinical senior research associate1,
- Jane Wardle, professor of clinical psychology2,
- Greg Rubin, professor of general practice and primary care3
- 1Institute of Public Health, University of Cambridge, Cambridge CB2 0SR, UK
- 2Health Behaviour Research Centre, University College London, London, UK
- 3School of Medicine, Pharmacy and Health, University of Durham, Durham, UK
We argued that multiple pre-referral consultations have a range of underlying causes, beyond the clinical reasoning skills of individual doctors.1 2 We therefore agree with Taylor that for some patients multiple pre-referral consultations will be generated by guideline concordant expectant management or investigations.3
Repeat consultations are nonetheless associated with longer times to referral, and efforts are needed to minimise their occurrence.2 For patients with low risk symptoms (not mandating immediate referral) in whom primary care led investigations are deemed necessary, the diagnostic process can be accelerated by shortening scheduling and reporting delays.3 The difficulty in coming to a diagnosis varies greatly by cancer.2 We agree that the diagnosis of lung cancer is particularly challenging,1 as detailed clinical audit and patient symptom studies show.4 5 6 Multifaceted approaches to reducing multiple pre-referral consultations include the development of novel tests, clinical audit activity (possibly triggered by multiple consultations in patients later diagnosed as having cancer), and the design of swift and integrated diagnostic care services that remove barriers between primary and specialist care.
In addition, system-wide approaches are needed to shorten prolonged intervals to presentation caused by psychosocial patient factors and to reduce avoidable delays that may occur after referral and within secondary care.2 There is unlikely to be a “quick fix” for the problem of multiple pre-referral consultations. Better appreciation of the complexity of the underlying causes is needed to make progress.
Cite this as: BMJ 2015;350:h433
Competing interests: None declared.