Intended for healthcare professionals

Practice Easily Missed?

New primary care series: Easily Missed?

BMJ 2009; 338 doi: (Published 19 February 2009) Cite this as: BMJ 2009;338:b491
  1. Anthony Harnden, university lecturer in general practice1,
  2. Richard Lehman, general practitioner2
  1. 1Department of Primary Health Care, University of Oxford, Oxford OX3 7LF
  2. 2Hightown Surgery, Banbury OX16 9DB
  1. Correspondence to: A Harnden anthony.harnden{at}

    The series advisers of this new series explain why heightened awareness is needed of conditions that may be commoner than many doctors realise or may be missed at first presentation

    Patients consult doctors with the expectation of an accurate diagnosis and advice on treatment. But in primary care, patients often present with undifferentiated symptoms without an immediately apparent diagnosis. For most conditions this doesn’t matter because the symptoms either resolve or become worse in such a way that the patient returns before any harm is done.1 In consultations, general practitioners work by using the probability that the collection of presenting symptoms reflects a specific diagnosis. A combination of knowledge, clinical experience, and sound judgment ensures that they usually get it right. The adage “common things are common” directly applies to diagnosis in primary care.2 In horse racing parlance, it is usually better to bet on a 6-4 chance than a 66-1 outsider. This, however, assumes that the doctor has an accurate idea of the prior odds3 and that no harm will result if a diagnosis thought to be less probable is made at a later consultation.

    But what if the condition is commoner than some general practitioners think and that without timely diagnosis patients may come to harm? The new series “Easily Missed?” aims to highlight such diagnoses to raise awareness among general practitioners of conditions that we believe are under-recognised in primary care at first presentation. The series will include a wide range of conditions, including some that are common but under-diagnosed and others that are uncommon but so serious that they need to be thought of whenever there is any possibility of their existence. The series will aim to be relevant to all those working in primary care, not only in the United Kingdom.

    The articles will be short and focused on diagnosis at presentation rather than treatment. The conditions described will fulfil four key criteria. Firstly, there will be evidence that the condition is commoner than most general practitioners realise or is often missed at first presentation. Secondly, the condition will be sufficiently common that the average full time general practitioner in the UK will encounter it at least once a year, or else be so serious that delayed diagnosis is likely to worsen prognosis substantially. Thirdly, the condition will have easily defined diagnostic features or diagnostic tests with known predictive characteristics. Fourthly, and most importantly, timely recognition will benefit the patient. As series advisers we welcome any suggestions for future articles on conditions that meet these criteria.

    Osler said “Medicine is a science of uncertainty and an art of probability.” Although uncertainty will always be with us in primary care, we hope the new series might teach us more about the art of probability.


    Cite this as: BMJ 2009;338:b491


    • doi:10.1136/bmj.a3058
    • doi:10.1136/bmj.b380
    • doi:10.1136/bmj.a3066
    • Contributors: Both authors proposed the concept of this new series and have worked with Mabel Chew (associate editor, BMJ) to develop a framework for future articles. AH and RL wrote the introduction. AH is guarantor.

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; not externally peer reviewed.


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