An Australian study (featured today in Medical Observer) has found prostate cancer patients are more likely to regret surgery than radiotherapy. This had me wondering; if my patient regrets surgery, should I then regret having referred them to a surgeon?
We would like to think our referrals are always based solely on the best outcomes, but can we really claim, as Edith Piaf did, Je ne regrette rien?
Or are we in fact sometimes swayed by factors other than outcomes – things like tradition, familiarity, friendships, or yesterday’s guidelines? It’s hard to identify any one referral as adamantly wrong, particularly if we self-reflect through rose-coloured lenses. But surely not every decision can be all La vie en rose.
If a GP refers to a surgeon in the private sector, the patient usually ends up getting surgery. Something about hammers seeing everything as nails?
So, radiologists advise further radiology and pathology begets pathology. Sure, some private urologists routinely consider re-referral for radiotherapy, but many don’t. This, despite a recent high-quality study showing both produce similar prostate cancer outcomes*.
If my preferred surgeon routinely ignores radiotherapy (and perhaps my radiation oncologist ignores surgery), then the humble GP’s choice of referral makes all the difference to the patient’s treatment. Perhaps it ideally shouldn’t be our call. But in practice, it often works out that way.
It’s not so simple, of course – often the urology referral is for diagnostic biopsy, by which time the train has left the station. And access to a radiation oncologist may be difficult.
But it underlines the general concept that the GP’s role as gatekeeper occasionally involves deciding who to shut out.
We close the gate to help our patients all the time, of course. We barely need think about it for a clearly inappropriate referral, but often the decision is more nuanced, and no two GPs have precisely identical referral thresholds.
For incontinence, will we refer to the physiotherapist or gynaecologist? For mental health, the psychologist or psychiatrist? We make a judgement call based on which treatment modality we feel is best for our patient, taking into account the likelihood of the specialist using that particular modality.
For example, now we know arthroscopies for osteoarthritic knees are essentially unhelpful, do we have some sort of duty not to refer our ageing patient to a knee specialist who spent the last two years learning advanced arthroscopic skills in New York and has a new private practice to pay off?
In the rose-coloured world, the orthopod would keep their arthroscope sheathed, citing the latest evidence of ineffectiveness. But la vie is not always so rose.
Yes, it’s a fortunate referrer who can say they regret nothing.
* The NEJM study, 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer, showed that of around 550 prostate ca patients randomised to surgery and the same number to radiotherapy, after 10 years five died in the surgery group and four died in the radiotherapy group.