1. Anaemia 1.1. 'When they have iron deficiency anaemia, initially we will be doing the ferritin test. If they’re low and straightforward we will give them treatment.' (GP2) 1.2. 'We always take the symptoms into account, to see whether anybody has got a bowel problem to start with. If there are associated features, like weight loss or passing blood in the stools or anything, then we investigate the first line management [in general practice].' (GP2) 1.3. Interviewer: 'How much time and effort do you think a good GP should spend to try and work out the diagnosis?' GP18:
' I think about two or three, maybe maximum four sessions with patient after having asked for investigation. At least two sessions.'
|
2. Diarrhoea 2.1 'Ideally, if there’s weight loss associated, as well as chronic diarrhoea, then definitely I will be looking for a cause.' (GP2) |
3. Rectal bleeding 3.1 'When somebody comes with PR bleeding, we do examination of PR but our knowledge is not 100%. And we get confused sometimes whether it's some anal problems or whether it's piles. Piles usually that's detectable. And anal fissure is significant. So then we are in a bit of a dilemma because it has happened with our practice and GPs, when they referred it turned out to be anal fissure, it's not cancer, when they had the colonoscopy and all that.' (GP18) |
4. Rectal examination
4.1 'I have seen cases, I've got patients with rectal bleeding and they’ve been told it's piles and its stopped and they have bleeding again, and every time its piles, piles, the doctor told me that — and it turned out to be rectal carcinoma.' (GP6) 4.2 '… And some people who are [were] treated as oh, it’s just piles and use the [FOBt] screen. Or the PR was not done.' (GP16) 4.3 '… Or where they've got a past history of piles and I'm satisfied that it's piles where I've PR'd them previously and they bleed again. It's difficult. You can't refer and you don't refer every single one that looks that way.' (GP17) |
5. Using an FOBt to decide
5.1 'If there is a bowel problem, bowel irregularities, we definitely check a stool for occult blood. We definitely do that.' (GP 18) 5.2 'Weight loss and occult blood test, if it is positive, definitely creates some kind of suspicion for us.' (GP18)5.3 'Quite often what we do is, when we're not sure exactly whether to refer or not, then we do an FOBt, and then of course according to the results we'll act on whatever is necessary.' (GP10) 5.4 'If the faecal occult blood is negative but the person has lost weight or has diarrhoea, I tell the patient that they don’t have to worry. If the patient is losing weight and having chronic diarrhoea then that needs to be looked into. I would still be referring them, even if their faecal occult blood is negative.' (GP2) 5.5. Interviewer: 'GPs have sometimes used FOBt as part of a preliminary process before they’ve thought about referral. We wondered if you’d seen it as part of that?' GP13:
That was very good teaching, ... So if they [patients] had no more symptoms, then I felt reassured [by the negative FOBt]. If they’ve got symptoms persisting then I won’t rely on it [FOBt]. If there are no symptoms persisting then I would rely on it.' |
6. Ordering further tests, sometimes doing in-house test to save money 6.1 'If we see microcytic anaemia in particular then we will not necessarily investigate them to the extent of sending them for a sigmoidoscopy but we will actually go through iron studies and we will ensure that we do a digital rectal examination or examine their abdomen and look for a cause. If we can't [find one], then we will refer.' (GP 15) 6.2 'If you think about 10 years ago, everybody who had diarrhoea was sent to the hospital, whether they were worried about cancer or not, and they were diagnosed in the hospital. Then all this cost and everything came up.' (GP2) |