- Email: [email protected]
CAN THE INITIAL CLINICAL ASSESSMENT OF THYROID FUNCTION BE IMPROVED?
933
,
if hospitals initiate treatment, the great bulk of prescribing will presumably be in general practice. In dispensing, a pharmacist is obliged to supply a proprietary product if a general practitioner names it but he may also dispense the proprietary product against a generic prescription. In the case of a patented drug he has no choice, but even when other preparations are available the pharmacist may prefer to stock only the proprietary product and to absorb the difference in price himself. Thus the lanoxin prescriptions would have led to lanoxin dispensing but a considerable and varying proportion of the digoxin prescribed may have been dispensed as lanoxin. The question of whether dispensing led to consumption is also unanswerable. Tablets may be swallowed, hoarded, or thrown away. A study in Belfast6 suggested that 36% of patients on digoxin were not taking the dose prescribed and another 14% were taking too much. However, the pattern of general-practitioner prescribing remains of interest. What effect did the bioavailability story have on prescribing patterns? Fig. 3 suggests that average dosages of all three preparations fell steadily throughout the decade. Although the dose of lanoxin diverged from that of digoxin there was no sudden drop in the former in 1972 or in the latter in 1975. Fig. 1 suggests that tablet frequency for lanoxin and digoxin full-strength 250 p.g tablets diverged in 1972 but the effect is small in contrast to an alleged doubling of potency of lanoxin. This may have been because doctors did not read or believe the warning letter, or because they found the whole story -that potency had doubled in May, 1972, but this was a reversion to pre-1970 strength-rather confusing. The inability of the profession en masse to detect changes in bioavailability is shown by the decline in the dose of lanoxin prescribed in the years 1969 to 1972 when its bioavailability is said to have halved. One trend that is apparent from 1972 is the increasing prescription of 250 p.g lanoxin rather than digoxin (fig. 2). While the generic prescription predominates in the full-strength tablets the proprietary prescription predominates in the quarterstrength, 62.5p.g tablets, perhaps because the proprietary product has no generic competitor and because of its more recent introduction and distinctive appearance. With the average daily frequency of all digoxin and lanoxin tablets running within a fairly narrow range in any year the average daily dose is largely determined by the tablet size. The tendency to prescribe 62.55 p.g tablets as lanoxin probably explains why lanoxin doses were lower than those of digoxin before the bioavailability story broke (fig. 3). During the past eleven years the average daily dose of digoxin and lanoxin has almost halved. If over that time the bioavailability had doubled then the biological effects would have remained constant. However, as already stated, much of the digoxin available in 1967 may have been of high bioavailability, so the question arises as to whether the level of digitalisation was too high in 1967 or is too low now. The increase in the number of people treated suggests that the popularity of the drug has not decreased. In the absence of historical data on the prevalence of cardiac failure in the over 65s it is not possible to state whether the threshold for initiating digitalisation has been reduced by the introduction of the low-dose tablets. However, the increase in prescribing is double that of the increase in over 65s in
the population and in 1975 the calculations done here would suggest that 6% of this age-group was on digoxin or lanoxin. Whether the downward trend in dosage continues or whether it levels off we shall not, unfortunately, be able to determine whether the decline has been caused by promotion of low-dose tablets, by the availability of other drugs for heart-failure and arrhythmias, or by a change of public and professional opinion towards less tolerance of possible drug toxicity. The individual prescribers who determine the average prescription each have to decide where the critical balance lies between the risk of iatrogenic disease from digitalis toxicity and the benefits of digitalisation, even at suboptimal dosage. This paper has been made possible by the generous release of confidential commercial data. It is interesting that the detailed monitoring of doctors’ prescribing behaviour has been left largely to commerce. Little has been done by the profession itself, and the published Health Service analyses are largely preoccupied with
costing. I thank Mr E. J. H. Osmond, of Intercontinental Medical Statistics Ltd, for providing information on and from the Medical Data Index,
and Dr G. Rowlands and his colleagues, of the Wellcome Foundation Ltd, for agreeing to its publication. REFERENCES
Johnson, B. F., Fowle, A. S. E., Lader, S., Fox, J., Munro-Faure, A. D. Br. med. J. 1973, iv, 323. 2. Shaw, T. R. D., Howard, M. R., Hamer, J. Lancet, 1972, ii, 303. 3. Shaw, T. R. D., Raymond, K., Howard, M. R., Hamer, J. Br. med. J. 1973, 1.
iv, 763. 4. Aronson, J. K., Grahame-Smith, D. G. Br. J. clin. Pharmac. 1976, 3, 639. 5. Smith, T. W., Haber, E. New Engl. J. Med. 1973, 289, 945, 1010, 1063, 1125. 6. Johnston, G. D., Kelly, J. G., McDevitt, D. G. Br. Heart J. 1978, 40, 1.
Hospital
Practice
CAN THE INITIAL CLINICAL ASSESSMENT OF THYROID FUNCTION BE IMPROVED? G. H. WHITE
R. N. WALMSLEY
Department of Clinical Biochemistry, Flinders Medical Centre, Bedford Park, South Australia 5042 The clinical reasons for requesting invitro thyroid-function tests were studied in 500 consecutive new patients with no known history of thyroid disease. 23 patients presented with five or more signs or symptoms of thyroid disease, and 18 of these required treatment for thyrometabolic dysfunction. Of 35 subjects with three or four thyroid-associated signs or symptoms, only 1 came to treatment. Of 442 subjects with one or two signs or symptoms, 2 were subsequently treated. These results suggest that there is little value in the biochemical investigation of patients who present with minimal clinical evidence of thyrometabolic disease.
Summary
INTRODUCTION
OVERT thyrometabolic disease (hyperthyroidism, hypothyroidism) is generally simple to diagnose clini-
934
and in-vitro thyroid-function tests are usually needed only to confirm the diagnosis and to provide a biochemical baseline for monitoring subsequent treatment. Since many of the signs and symptoms associated with thyroid dysfunction are non-specific and may be seen both in health and in many euthyroid diseases, biochemical investigation is important for the diagnosis of mild or early thyroid disease. Because thyroid disease is one of the commonest endocrine disorders, and also because specific hormone assays are available, physicians are tending to request thyroid-hormone assays for patients who have only one or two thyroid-associated signs or symptoms. To evaluate the benefits of such an approach we have reviewed the clinical and biochemical findings from a series of consecutive new patients referred to our thyroid laboratory.
cally,
METHODS AND RESULTS
Laboratory
Tests
Serum total thyroxine (TJ, triiodothyronine (T 3)’ and, thyrotrophin (T.S.H.) were estimated with radioimmunoassay of unextracted serum. The T3 resin-uptake ratio (T3R.U.R.) 1
determined with the method of Liewendahl and Helenius. free-thyroxine ratio (F.T.I.) was calculated from the relationship, F.T.I.=T4xT3R.U.R.2 Reference ranges (mean±2 s.D.) were determined from 130 blood-donor sera. T4 and F.T.I. were assayed in all sera referred for thyroidfunction tests. Further tests (T.s.H., T3, T.S.H. response to thyrotrophin-releasing hormone) were done if indicated by the initial test results and clinical history.
TABLE II-DEGREE OF CLINICAL SUSPICION OF THYROID DISEASE IN
500
NEW
PATIENTS,
AND NUMBERS IN WHOM THYROID DISEASE
WAS FINALLY DIAGNOSED
clinical suspicion was based on the generally accepted signs and symptoms of thyrometabolic disease (table I) and was determined for each of the 500 patients (table n). The number of patients within each category of clinical suspicion in whom thyroid disease was diagnosed with biochemical tests are shown in table n.
was
The
Patients 500 consecutive new inpatients and outpatients were selected from our 1977 thyroid register. Patients with a known history of thyroid disease were excluded. The following information was obtained from each patient’s case-notes: (i) thyroidfunction-test results; (ii) the patient’s clinical signs and symptoms noted by the clinician during the consultation from which the referral for thyroid-function studies originated; and (iii) subsequent clinical diagnosis of thyroid status. The degree of
TABLE
AND CLINICAL SUSPICION OF
I-SIGNS, SYMPTOMS,
THYROID DYSFUNCTION RANGE OF SIGNS AND SYMPTOMS RECORDED DURING THE STUDY
(i) Thyrometabolic.-Goitre, thyroid bruit, fine tremor, weight loss, appetite, lid lag, sweating, heat intolerance, family history, lethargy, weight-gain, hoarseness, dry skin, hair-loss, cold intolerance, delayed reflex, constipation, short stature. increased
(ii)
Cardiovascular.-Recent
myocardial infarct,
chronic cardiac
failure, coronary-artery disease, arrhythmias, pulse-rate >90/min,
hypertension. (iii) Others.-eg., pneumonia, asthma, diabetes. DEGREE OF CLINICAL SUSPICION
High.-Patient presenting with
5
or more
signs/symptoms listed in
groups (i) and (ii). Intermediate.-Patients listed in groups (i) and (ii). Low.-Patient
(i), (ii), or (iii).
presenting
presenting
with 1
or
with 3
2
or
4
signs/symptoms
signs/symptoms from groups
DISCUSSION
Although thyroid disease is one of the common endocrine disorders, the natural history and estimated incidence of the disease (about 0.3%)3 do not warrant the heavy economic and logistic burden of biochemical screening for the general population. Clinicians therefore must identify patients for whom biochemical investigation of thyroid disease is worth while. Of the 500 patients in this study 4.2% were found to have thyroid dysfunction requiring treatment-a reasonable clinical yield when compared with the estimated incidence of the disease. As would be expected, the majority of patients (78%) presenting with five or more thyroid-associated signs or symptoms subsequently came to treatment (high degree of clinical suspicion, table II). Surprisingly, only 3% of patients with 3 or 4 signs or symptoms required treatment (intermediate degree of clinical suspicion), but if the high and intermediate categories are considered together, there is still a very good clinical yield of 33%. However, 88.4% of the laboratory workload arising from this study was concerned with investigating patients who presented with minimal clinical evidence of thyrometabolic disease. Of these 442 patients, only 2 (<0’3%) required treatment (table II). All these subjects had had a full medical examination. This is a very poor clinical yield, suggesting that thyroid-function tests on patients presenting with only one or two thyroid-associated signs or symptoms are unproductive. Although early detection was of benefit to the 2 patients identified, it is unlikely that deferment of treatment for a few months (until thyroid disease was more clinically obvious) would have been harmful. In this study 18 of the 21 (86%) subsequently treated patients did not come to medical attention until they had five or more signs or symptoms of thyroid dysfunction. The basic metabolic importance of thyroid hormones is reflected in the multiple symptoms generally observed when thyroid function is disturbed. Therefore the physician should be looking for a group of thyrometabolic signs and symptoms: thyroid-function tests on subjects
935
only one or two non-specific symptoms-such anxiety, lassitude, weight change, constipation,
with
as or
cardiovascular disease-have no value. Many laboratories do a serum-thyroxine assay, free
thyroxine index, or effective thyroxine ratio as their initial test of thyroid function. These assays are often referred to as screening tests, and unfortunately this term often carries an unwarranted implication of low cost rather than speed of estimation. Laboratories must attempt to assess the value and effectiveness of the diagnostic strategies used by their clinical colleagues. The diagnosis of thyroid disease is a clinical problem, and therefore the initial screening of patients should be done by the physician and not the diagnostic laboratory. The physician must be freely able to test his clinical opinion, but the present evidence indicates a need for a substantial improvement in the selection of patients for thyroidfunction testing. 1. 2. 3.
Liewendahl, K., Helenius,
REFERENCES T. Clinica chim. Acta,
1975, 64, 263.
Clark, F., Horn, D.B.J. clin. Endocr. 1965, 25, 39. Tunbridge, W. M. G., Evered, D. C., Hall, R., et al.
Clin. Endocr. 1977,
7,
481.
Medical Education TEACHING WHAT TO SAY ABOUT CANCER R. L. SOUHAMI
University College Hospital,
Gower Street, London WC1
INTRODUCTION
MEDICAL students who have had no chance to discuss with their teachers the difficulties of talking to patients with cancer may try to avoid worrying and unpleasant discussions of this sort when qualified. Where talking to patients on such difficult matters is taught, the methods are often inadequate. Lectures on "the care of the dying" or "psychological aspects of disease" lack an essential ingredient: the words and feelings of the patient. Joint discussions by students with a psychiatrist and a patient as part of the teaching on medical and surgical wards, or with a medical social worker at a case conference, also lack something: the views of the physician or surgeon responsible for the patient. Asking a psychiatrist or social worker to guide students on what to tell patients about the diagnosis of cancer is not a good example to set. Feelings and emotions engendered by malignant disease cannot be left to psychiatrists while the doctor has a crack at the tumour. Students learn about physical disease from seeing clinician and patient together. But they are usually excluded from private discussions in which the experienced physician tries to find out what the patient wants to know about a potentially fatal disease; they may be told about only the outcome. Many students are left at a loss. These decisions are difficult, but how do you decide what to say?
When allowed to express a view, some students are openly critical of both the lack of their involvement and the results of decisions made in relation to patients by doctors who seerri sometimes reluctant to talk to their patients about the diagnosis. Just as students learn other clinical skills from seeing patients with clinicians, so they can be taught about this most difficult aspect of patient care in the same way. I try to do this with students on my unit.
THE INTERVIEW
Four or five students are on the unit for two months and I make one of our weekly tutorials an occasion for discussion with a patient who seems to me to be able to talk in front of students. I try not to be influenced by the patient’s occupation, fluency, or technical knowledge. I tell the patient that the students need to learn of patients’ feelings about cancer, their reactions to being told the diagnosis, and their reactions to what doctors have said. The patient has one or two weeks to think over the suggestion. All except one has agreed; many have jumped at the opportunity. The patient comes to the meeting aware that he can be critical if he wishes, and that he need not answer awkward or embarrassing questions. The patient begins by describing his first symptoms, who he went to see, his treatment, and what his symptoms are now. It is important to get the details clear with as little interruption as possible. This history is more than a description of the medical problem. Going back over the details provokes memories and helps the patient to talk confidently and easily in front of students. It also sets the scene for the next and most important part of the discussion, in which the patient describes his feelings about his first symptoms before he first saw a doctor, what his family doctor and specialist said and his reactions, what was said after the operation and whether he understood or believed the explanation, what he said to his family, their reaction, whether friends or relatives had had a similar disease, and whether he read about his disease in books and papers. The patient is not subjected to a barrage of questions: the answers are apparent as the patient relives some of the most vivid moments of his life. The details always show the complexity of human feelings, of family ties, of relationships with friends and children. The sources of information and clues about his disease, outside the hospital or clinic, are shown to be subtle and varied.
THE
PATIENTS’
EXPERIENCES
The patient’s reaction to the very first symptom is often highly revealing and sometimes makes the response of doctors seem slightly ridiculous. The first symptom of a 65-year-old businessman with carcinoma of the bronchus was a lump in the neck which he noticed while shaving. His wife had had cancer of the breast, treated by mastectomy, 18 years previously. "Well, I thought nothing of the lump, but I mentioned it to the wife before I went to work. She didn’t say a word but I knew from the look in her eyes that she thought I had cancer. She’d always said she was more worried about me getting it than she had been about herself."
,
if hospitals initiate treatment, the great bulk of prescribing will presumably be in general practice. In dispensing, a pharmacist is obliged to supply a proprietary product if a general practitioner names it but he may also dispense the proprietary product against a generic prescription. In the case of a patented drug he has no choice, but even when other preparations are available the pharmacist may prefer to stock only the proprietary product and to absorb the difference in price himself. Thus the lanoxin prescriptions would have led to lanoxin dispensing but a considerable and varying proportion of the digoxin prescribed may have been dispensed as lanoxin. The question of whether dispensing led to consumption is also unanswerable. Tablets may be swallowed, hoarded, or thrown away. A study in Belfast6 suggested that 36% of patients on digoxin were not taking the dose prescribed and another 14% were taking too much. However, the pattern of general-practitioner prescribing remains of interest. What effect did the bioavailability story have on prescribing patterns? Fig. 3 suggests that average dosages of all three preparations fell steadily throughout the decade. Although the dose of lanoxin diverged from that of digoxin there was no sudden drop in the former in 1972 or in the latter in 1975. Fig. 1 suggests that tablet frequency for lanoxin and digoxin full-strength 250 p.g tablets diverged in 1972 but the effect is small in contrast to an alleged doubling of potency of lanoxin. This may have been because doctors did not read or believe the warning letter, or because they found the whole story -that potency had doubled in May, 1972, but this was a reversion to pre-1970 strength-rather confusing. The inability of the profession en masse to detect changes in bioavailability is shown by the decline in the dose of lanoxin prescribed in the years 1969 to 1972 when its bioavailability is said to have halved. One trend that is apparent from 1972 is the increasing prescription of 250 p.g lanoxin rather than digoxin (fig. 2). While the generic prescription predominates in the full-strength tablets the proprietary prescription predominates in the quarterstrength, 62.5p.g tablets, perhaps because the proprietary product has no generic competitor and because of its more recent introduction and distinctive appearance. With the average daily frequency of all digoxin and lanoxin tablets running within a fairly narrow range in any year the average daily dose is largely determined by the tablet size. The tendency to prescribe 62.55 p.g tablets as lanoxin probably explains why lanoxin doses were lower than those of digoxin before the bioavailability story broke (fig. 3). During the past eleven years the average daily dose of digoxin and lanoxin has almost halved. If over that time the bioavailability had doubled then the biological effects would have remained constant. However, as already stated, much of the digoxin available in 1967 may have been of high bioavailability, so the question arises as to whether the level of digitalisation was too high in 1967 or is too low now. The increase in the number of people treated suggests that the popularity of the drug has not decreased. In the absence of historical data on the prevalence of cardiac failure in the over 65s it is not possible to state whether the threshold for initiating digitalisation has been reduced by the introduction of the low-dose tablets. However, the increase in prescribing is double that of the increase in over 65s in
the population and in 1975 the calculations done here would suggest that 6% of this age-group was on digoxin or lanoxin. Whether the downward trend in dosage continues or whether it levels off we shall not, unfortunately, be able to determine whether the decline has been caused by promotion of low-dose tablets, by the availability of other drugs for heart-failure and arrhythmias, or by a change of public and professional opinion towards less tolerance of possible drug toxicity. The individual prescribers who determine the average prescription each have to decide where the critical balance lies between the risk of iatrogenic disease from digitalis toxicity and the benefits of digitalisation, even at suboptimal dosage. This paper has been made possible by the generous release of confidential commercial data. It is interesting that the detailed monitoring of doctors’ prescribing behaviour has been left largely to commerce. Little has been done by the profession itself, and the published Health Service analyses are largely preoccupied with
costing. I thank Mr E. J. H. Osmond, of Intercontinental Medical Statistics Ltd, for providing information on and from the Medical Data Index,
and Dr G. Rowlands and his colleagues, of the Wellcome Foundation Ltd, for agreeing to its publication. REFERENCES
Johnson, B. F., Fowle, A. S. E., Lader, S., Fox, J., Munro-Faure, A. D. Br. med. J. 1973, iv, 323. 2. Shaw, T. R. D., Howard, M. R., Hamer, J. Lancet, 1972, ii, 303. 3. Shaw, T. R. D., Raymond, K., Howard, M. R., Hamer, J. Br. med. J. 1973, 1.
iv, 763. 4. Aronson, J. K., Grahame-Smith, D. G. Br. J. clin. Pharmac. 1976, 3, 639. 5. Smith, T. W., Haber, E. New Engl. J. Med. 1973, 289, 945, 1010, 1063, 1125. 6. Johnston, G. D., Kelly, J. G., McDevitt, D. G. Br. Heart J. 1978, 40, 1.
Hospital
Practice
CAN THE INITIAL CLINICAL ASSESSMENT OF THYROID FUNCTION BE IMPROVED? G. H. WHITE
R. N. WALMSLEY
Department of Clinical Biochemistry, Flinders Medical Centre, Bedford Park, South Australia 5042 The clinical reasons for requesting invitro thyroid-function tests were studied in 500 consecutive new patients with no known history of thyroid disease. 23 patients presented with five or more signs or symptoms of thyroid disease, and 18 of these required treatment for thyrometabolic dysfunction. Of 35 subjects with three or four thyroid-associated signs or symptoms, only 1 came to treatment. Of 442 subjects with one or two signs or symptoms, 2 were subsequently treated. These results suggest that there is little value in the biochemical investigation of patients who present with minimal clinical evidence of thyrometabolic disease.
Summary
INTRODUCTION
OVERT thyrometabolic disease (hyperthyroidism, hypothyroidism) is generally simple to diagnose clini-
934
and in-vitro thyroid-function tests are usually needed only to confirm the diagnosis and to provide a biochemical baseline for monitoring subsequent treatment. Since many of the signs and symptoms associated with thyroid dysfunction are non-specific and may be seen both in health and in many euthyroid diseases, biochemical investigation is important for the diagnosis of mild or early thyroid disease. Because thyroid disease is one of the commonest endocrine disorders, and also because specific hormone assays are available, physicians are tending to request thyroid-hormone assays for patients who have only one or two thyroid-associated signs or symptoms. To evaluate the benefits of such an approach we have reviewed the clinical and biochemical findings from a series of consecutive new patients referred to our thyroid laboratory.
cally,
METHODS AND RESULTS
Laboratory
Tests
Serum total thyroxine (TJ, triiodothyronine (T 3)’ and, thyrotrophin (T.S.H.) were estimated with radioimmunoassay of unextracted serum. The T3 resin-uptake ratio (T3R.U.R.) 1
determined with the method of Liewendahl and Helenius. free-thyroxine ratio (F.T.I.) was calculated from the relationship, F.T.I.=T4xT3R.U.R.2 Reference ranges (mean±2 s.D.) were determined from 130 blood-donor sera. T4 and F.T.I. were assayed in all sera referred for thyroidfunction tests. Further tests (T.s.H., T3, T.S.H. response to thyrotrophin-releasing hormone) were done if indicated by the initial test results and clinical history.
TABLE II-DEGREE OF CLINICAL SUSPICION OF THYROID DISEASE IN
500
NEW
PATIENTS,
AND NUMBERS IN WHOM THYROID DISEASE
WAS FINALLY DIAGNOSED
clinical suspicion was based on the generally accepted signs and symptoms of thyrometabolic disease (table I) and was determined for each of the 500 patients (table n). The number of patients within each category of clinical suspicion in whom thyroid disease was diagnosed with biochemical tests are shown in table n.
was
The
Patients 500 consecutive new inpatients and outpatients were selected from our 1977 thyroid register. Patients with a known history of thyroid disease were excluded. The following information was obtained from each patient’s case-notes: (i) thyroidfunction-test results; (ii) the patient’s clinical signs and symptoms noted by the clinician during the consultation from which the referral for thyroid-function studies originated; and (iii) subsequent clinical diagnosis of thyroid status. The degree of
TABLE
AND CLINICAL SUSPICION OF
I-SIGNS, SYMPTOMS,
THYROID DYSFUNCTION RANGE OF SIGNS AND SYMPTOMS RECORDED DURING THE STUDY
(i) Thyrometabolic.-Goitre, thyroid bruit, fine tremor, weight loss, appetite, lid lag, sweating, heat intolerance, family history, lethargy, weight-gain, hoarseness, dry skin, hair-loss, cold intolerance, delayed reflex, constipation, short stature. increased
(ii)
Cardiovascular.-Recent
myocardial infarct,
chronic cardiac
failure, coronary-artery disease, arrhythmias, pulse-rate >90/min,
hypertension. (iii) Others.-eg., pneumonia, asthma, diabetes. DEGREE OF CLINICAL SUSPICION
High.-Patient presenting with
5
or more
signs/symptoms listed in
groups (i) and (ii). Intermediate.-Patients listed in groups (i) and (ii). Low.-Patient
(i), (ii), or (iii).
presenting
presenting
with 1
or
with 3
2
or
4
signs/symptoms
signs/symptoms from groups
DISCUSSION
Although thyroid disease is one of the common endocrine disorders, the natural history and estimated incidence of the disease (about 0.3%)3 do not warrant the heavy economic and logistic burden of biochemical screening for the general population. Clinicians therefore must identify patients for whom biochemical investigation of thyroid disease is worth while. Of the 500 patients in this study 4.2% were found to have thyroid dysfunction requiring treatment-a reasonable clinical yield when compared with the estimated incidence of the disease. As would be expected, the majority of patients (78%) presenting with five or more thyroid-associated signs or symptoms subsequently came to treatment (high degree of clinical suspicion, table II). Surprisingly, only 3% of patients with 3 or 4 signs or symptoms required treatment (intermediate degree of clinical suspicion), but if the high and intermediate categories are considered together, there is still a very good clinical yield of 33%. However, 88.4% of the laboratory workload arising from this study was concerned with investigating patients who presented with minimal clinical evidence of thyrometabolic disease. Of these 442 patients, only 2 (<0’3%) required treatment (table II). All these subjects had had a full medical examination. This is a very poor clinical yield, suggesting that thyroid-function tests on patients presenting with only one or two thyroid-associated signs or symptoms are unproductive. Although early detection was of benefit to the 2 patients identified, it is unlikely that deferment of treatment for a few months (until thyroid disease was more clinically obvious) would have been harmful. In this study 18 of the 21 (86%) subsequently treated patients did not come to medical attention until they had five or more signs or symptoms of thyroid dysfunction. The basic metabolic importance of thyroid hormones is reflected in the multiple symptoms generally observed when thyroid function is disturbed. Therefore the physician should be looking for a group of thyrometabolic signs and symptoms: thyroid-function tests on subjects
935
only one or two non-specific symptoms-such anxiety, lassitude, weight change, constipation,
with
as or
cardiovascular disease-have no value. Many laboratories do a serum-thyroxine assay, free
thyroxine index, or effective thyroxine ratio as their initial test of thyroid function. These assays are often referred to as screening tests, and unfortunately this term often carries an unwarranted implication of low cost rather than speed of estimation. Laboratories must attempt to assess the value and effectiveness of the diagnostic strategies used by their clinical colleagues. The diagnosis of thyroid disease is a clinical problem, and therefore the initial screening of patients should be done by the physician and not the diagnostic laboratory. The physician must be freely able to test his clinical opinion, but the present evidence indicates a need for a substantial improvement in the selection of patients for thyroidfunction testing. 1. 2. 3.
Liewendahl, K., Helenius,
REFERENCES T. Clinica chim. Acta,
1975, 64, 263.
Clark, F., Horn, D.B.J. clin. Endocr. 1965, 25, 39. Tunbridge, W. M. G., Evered, D. C., Hall, R., et al.
Clin. Endocr. 1977,
7,
481.
Medical Education TEACHING WHAT TO SAY ABOUT CANCER R. L. SOUHAMI
University College Hospital,
Gower Street, London WC1
INTRODUCTION
MEDICAL students who have had no chance to discuss with their teachers the difficulties of talking to patients with cancer may try to avoid worrying and unpleasant discussions of this sort when qualified. Where talking to patients on such difficult matters is taught, the methods are often inadequate. Lectures on "the care of the dying" or "psychological aspects of disease" lack an essential ingredient: the words and feelings of the patient. Joint discussions by students with a psychiatrist and a patient as part of the teaching on medical and surgical wards, or with a medical social worker at a case conference, also lack something: the views of the physician or surgeon responsible for the patient. Asking a psychiatrist or social worker to guide students on what to tell patients about the diagnosis of cancer is not a good example to set. Feelings and emotions engendered by malignant disease cannot be left to psychiatrists while the doctor has a crack at the tumour. Students learn about physical disease from seeing clinician and patient together. But they are usually excluded from private discussions in which the experienced physician tries to find out what the patient wants to know about a potentially fatal disease; they may be told about only the outcome. Many students are left at a loss. These decisions are difficult, but how do you decide what to say?
When allowed to express a view, some students are openly critical of both the lack of their involvement and the results of decisions made in relation to patients by doctors who seerri sometimes reluctant to talk to their patients about the diagnosis. Just as students learn other clinical skills from seeing patients with clinicians, so they can be taught about this most difficult aspect of patient care in the same way. I try to do this with students on my unit.
THE INTERVIEW
Four or five students are on the unit for two months and I make one of our weekly tutorials an occasion for discussion with a patient who seems to me to be able to talk in front of students. I try not to be influenced by the patient’s occupation, fluency, or technical knowledge. I tell the patient that the students need to learn of patients’ feelings about cancer, their reactions to being told the diagnosis, and their reactions to what doctors have said. The patient has one or two weeks to think over the suggestion. All except one has agreed; many have jumped at the opportunity. The patient comes to the meeting aware that he can be critical if he wishes, and that he need not answer awkward or embarrassing questions. The patient begins by describing his first symptoms, who he went to see, his treatment, and what his symptoms are now. It is important to get the details clear with as little interruption as possible. This history is more than a description of the medical problem. Going back over the details provokes memories and helps the patient to talk confidently and easily in front of students. It also sets the scene for the next and most important part of the discussion, in which the patient describes his feelings about his first symptoms before he first saw a doctor, what his family doctor and specialist said and his reactions, what was said after the operation and whether he understood or believed the explanation, what he said to his family, their reaction, whether friends or relatives had had a similar disease, and whether he read about his disease in books and papers. The patient is not subjected to a barrage of questions: the answers are apparent as the patient relives some of the most vivid moments of his life. The details always show the complexity of human feelings, of family ties, of relationships with friends and children. The sources of information and clues about his disease, outside the hospital or clinic, are shown to be subtle and varied.
THE
PATIENTS’
EXPERIENCES
The patient’s reaction to the very first symptom is often highly revealing and sometimes makes the response of doctors seem slightly ridiculous. The first symptom of a 65-year-old businessman with carcinoma of the bronchus was a lump in the neck which he noticed while shaving. His wife had had cancer of the breast, treated by mastectomy, 18 years previously. "Well, I thought nothing of the lump, but I mentioned it to the wife before I went to work. She didn’t say a word but I knew from the look in her eyes that she thought I had cancer. She’d always said she was more worried about me getting it than she had been about herself."