Three times beware

First time – duration and severity
Second time -patterns and precedent
Third Time beware – act and review

When a person presents three times with similar or possibly linked problems over a period of three months or less a doctor should have a heightened awareness and persist in checking all possibilities.

We are not considering a simple clear cut diagnosis here, but looking at the common situation in general practice where things are uncertain and unclear.

People present with many different minor symptoms and the skill of a general practitioner is in sifting out what is serious from what is self limiting. A doctor needs to explain and advise on how to handle these self limiting conditions so that the individual learns how to manage it themselves without needing advice.

First time – duration and severity

The symptoms are a key feature in diagnosis, but the majority of the time a doctor will consider the “duration, severity and symptoms”.

A minor symptom present for half an hour is unlikely to be serious (People do present with half an hour of sore throat, or diarrhoea). A symptom present for a few days or up to two weeks can often be observed if not serious.

Three months is a difficult period since this suggests investigation is needed, too long for observation and therefore a risk period. Six months or more tends to be reassuring as serious causes should have emerged by then.

Severity can be assessed by the impact on day to day life. If the person says they carry on as normal and take no painkillers then serious causes may be less likely

Second time -patterns and precedent

Patterns may emerge and good records help you to detect this. A “precedent set” diagnosis is one where the same symptoms were managed before and resolved. Build on from the previous treatments used, which are often just the judicious use of time.

Third Time beware – act and review

Beware, whatever the symptoms, however minor, there is likely to be an underlying problem. Lower your threshold for action in the form of examination or investigations. Arrange review to ensure you watch out for new symptoms as clues and ensure the patient and their family are aware you have taken things seriously

Even if no physical illness presents over time there is likely to be underlying anxiety or psychological issues which you can help to address

Case Study

I am looking at the day’s visit list wondering which patient needs my attention and how many doctors are available. I plump for Mrs A as I recognize her name and start to get a mental picture of her in her bungalow with her small dog. That is the third time Mrs A has called us this fortnight I note as I look through her records. Once with my GP partner and once with the GP Registrar, neither of whom are here today.

I skim through the number of records on the computer to see if they are “thin or thick”. In the past this was a physical activity. A5 size Lloyd George records crammed with folded paper, in a rough date order. If our receptionist Margaret walked in with a waddle holding three bulging brown packs you knew it would be complex. If a thin pristine pack skittered across the table your concern rose. Perhaps a fit octogenarian asking for a visit or a medical person who rarely attended, came to mind. A thin note consultation needed more focus, a thick noted consultation needed more time.

Mrs A’s electronic records are relatively thin with no visits and few consultations. The last two visits were non specific headache, back achy, unwell. No particular pointers to the cause but “it’s a virus doc” comes to mind.

Third time round I muse to myself. Need to take more care. Memories of the back pain that was prostatic secondaries float by and the man with the leaking aortic aneurysm. Both at home and comfortable just now. I dismiss Mrs A’s absence prostate and look through her past history for clues. Nothing of note, gallbladder out

There is something not right I sense later when examining her at home. In bed nightgowned and slightly pale. Nothing else to add other than feeling a bit bloated. But she is not managing at home and this is the “third time”. Mrs A lives on her own she is not eating and is having difficulty reaching the toilet and kitchen. First time the doctor “observed”. Second time the doctor did bloods – all normal. Third time requires action.

I mentally prepare a carefully crafted letter selling the problem to the medical team. A mixture of embarrassment that I do not have the answer and determination to work through the system Expecting a rough ride from a pressurized junior doctor I am relieved to speak to an experienced consultant who understands the scenario and appreciates the “third time and beware” rule.

A couple of weeks later the answer falls onto my desk amidst the daily pile of paperwork. Ovarian carcinoma detected on ultrasound. How much longer could we have sat on this I wonder as I breathe a sigh of relief. Relief that we have not missed it, relief that it was not a wasted admission, tinged with sadness over what awaits Mrs A. A mental prayer of thanks for the third time and beware rule. Other factors were clues but they can be missed unless you step back, take a breath, think more carefully about the situation.

Third time and beware is the watchword.

All cases are aggregated and therefore unrelated to individualswith fictional names