Friday 27th November 1992   Respiratory Disease Performance Panel 08:15

“Good morning Dr Dennis. Welcome to the panel. I would like to start by introducing everyone. I am Professor Melanie Mortimer, Specialist Consultant in Adult Respiratory Medicine at The Royal Brompton Hospital. I am pleased to be able to welcome two esteemed respiratory colleagues. Next to me, on my right, is Dr Matt Montague. Matt is one of the Consultants in Alder Hey Hospital. He has a particular interest in asthma in children. On my left is Dr Malcolm Morrison. I am sure you know Malcolm. He is a Consultant Respiratory Physician in Portmere Hospital.”
My Dad smiled at the three consultants.
Professor Mortimer continued: “As you know, you have been charged with making an irresponsible diagnosis of asthma on at least five separate occasions. It is Dr Malcolm Morrison who initially reported these, shall we call them, shortcomings.  We have had a good look each patient’s medical record. Four of the patients are adults and one is a child. As far as the adults are concerned, we feel that the circumstances are all very similar. We would, therefore, like to go through one case in detail with you.”
My Dad nodded.
“The patient we have chosen is a Mr Peter Purvis. He is 27 years old and he has been registered with you ever since his birth. Apart from the usual childhood illnesses, he has rarely needed to come to see the doctor. Now . . . on the 23rd November last year, Mr Purvis came to see you with what you have documented as an acute bronchitis. You noted that he had had a cold and a cough for a week. He had been coughing up some green sputum. He was slightly breathless. He thought he’d had a temperature and he had been feeling mildly shivery at times. Mr Purvis has never smoked and he has had no previous chest problems. Do you remember the case, Dr Dennis?”
“I do.”
“You examined his chest. There was a little wheeziness. You also measured his peak expiratory flow rate which was 500.”
My Dad nodded.
“Excuse me, Professor Mortimer. Can I ask Dr Dennis a question?”
“Of course, Malcolm.”
“OK, Dr Dennis, what sort of peak flow rate would you expect in a patient like Mr Purvis?”
“I would imagine it would be about 600.”
Dr Morrison frowned gravely. “I am afraid things really aren’t as simple as that Dr Dennis. It depends on . . .”
“That does seem a reasonable ball park figure, Dr Morrison.” Professor Mortimer said as she glanced down at the Mr Purvis’ records. “Right, you prescribed an antibiotic, Dr Dennis, and asked Mr Purvis to come back and see you if things didn’t settle down. I think we can assume that he did improve because you did not see him again until the 2nd May when he consulted with further chest problems. On this occasion, he had not had much of a cold. He had had a dry cough. He was fairly wheezy and finding it difficult to sleep at night. You examined him and found a lot of wheeze, expiratory wheeze in both lungs. You have described the wheeze as . . . I can’t read this . . . ah, yes . . . as polyphonic wheeze.”
Both Dr Morrison and Dr Montague chuckled and raised their eyebrows.
“Let me carry on please, gentlemen. This time, Mr Peter Purvis’s peak expiratory flow rate was 400, considerably lower than in November.”
“Yes, it was,” my Dad said.
“You did not specifically mention that you suspected asthma but you did note that there was no family history of asthma. You also stated that the patient was suffering from hay fever.”
“Excuse me, Professor Mortimer. Can I ask Dr Dennis another question?”
“Of course, Malcolm.”
“OK, Dr Dennis, can you tell me what diagnostic criteria you use to make a diagnosis of hay fever or allergic rhinitis?”
“Mmm,” My Dad said. “Do you know, I have never really thought about it. To be honest, I think most of our patients make the diagnosis themselves. If I remember correctly, Peter told me he had hay fever.”
“Your patients make the diagnosis of hay fever themselves!” Dr Malcolm Morrison looked extremely worried. “How irregular!” He shook his head.
“Even though you did not make a diagnosis of asthma,” continued Professor Mortimer, “you prescribed treatment usually used for asthma: a ventolin inhaler and a course of steroid tablets.”
“That’s correct,” said my Dad. “He was quite wheezy as I have noted.”
“You also asked the patient to come back in two weeks to make sure that his symptoms had settled down.”
“I did.”
“You saw Mr Purvis again on the 15th May. By this time, he was feeling much better His chest was completely clear and his peak expiratory flow rate was 620.”
“His peak flow had come up quite nicely with the treatment,” my Dad said.
“On the 28th of July, Mr Purvis was back. This time, he had not had a cold. After cutting his lawn at the weekend, he had started to feel wheezy. This got gradually worse over the next few days resulting in him coming to see you on the Tuesday. His chest was really very wheezy and his peak expiratory flow rate was down to 350. You recommended that he restarted his ventolin inhaler and you gave him a further course of steroid tablets. Two weeks later, he had again improved. His chest was completely clear and his peak expiratory flow rate was back up to 610. It was at this stage you made a diagnosis of asthma and suggested that Mr Purvis started taking a preventative inhaler; incidentally, a rather expensive treatment. Anyway, this seems to have done the trick because, at the end of October when Mr Purvis came to see the asthma nurse, he was feeling his normal self, he had not had to use his blue inhaler at all and he had not had any further wheezy episodes.”

Professor Mortimer looked up from the notes. “We are not quite sure, Dr Dennis, how you came to the conclusion that Mr Purvis had asthma.”
“You don’t seem to have considered arranging spirometry,” said Dr Montague. “Isn’t it likely that Mr Purvis simply had a chest infection that had not completely cleared up or was it possible that he had had three chest infections, one after another?
“I don’t think so,” my Dad said.
“Could this just have been three temporary episodes of wheeziness?” Dr Montague continued.
“Isn’t that what asthma is?” my Dad asked.
“Did you think about requesting an opinion from Dr Morrison?” Professor Mortimer wondered.
“Well, I didn’t think it was really necessary,” my Dad said. “Dr Morrison has got a very long waiting list. It is about 12 months for a non-urgent referral.”

“Well, let’s get on to the next case,” Professor Mortimer spoke impatiently. “This is the child who supposedly has asthma. Would you like to lead on this, Matt?”
“Of course, Melanie. This case is also causing us all a great deal of anxiety, Dr Dennis. Now, young Philip Padgett was just 3 years old. You saw him with six separate episodes of wheeziness. After the sixth episode, you made a diagnosis of asthma and started him on a preventative inhaler. Interestingly, this was the same expensive treatment that you started Mr Purvis on although, obviously, you used a lower dose. To be fair, you also prescribed a spacer.”
“You seem to have made a diagnosis of asthma here with absolutely no objective measurements,” Dr Morrison interjected.
“It is very difficult to make objective measurements in a 3 year old, Dr Morrison.” My Dad said.
“I am afraid I do have to agree with Dr Dennis there,” Dr Montague said. “You did note that Philip’s older brother is asthmatic. However, I am not sure that we can say that the younger brother of every asthmatic patient is also likely to be asthmatic.”
“No, but it is something I always take into account, Dr Montague.”
“Mmm . . . I think you have done more than taken it into account. As a general rule, Dr Dennis, in the field of paediatric respiratory medicine, I can say with some authority that one never makes a diagnosis of asthma in a child under 4 years old. I find it most disconcerting that you have diagnosed asthma so readily in this young child. I presume that you have a paediatric department in your local hospital? If that’s the case, I can’t see why you haven’t used it.”
“Hear! Hear!” Dr Morrison exclaimed. “I agree completely. Anyway, Matt, wouldn’t it have been more appropriate to call this child a happy wheezer rather than an asthmatic?”
“Actually,” my Dad said, “he wasn’t really a happy wheezer. He seemed to get very frightened when his breathing was bad.”
“I don’t think the term ‘happy wheezer’ means a wheezy child of a happy demeanour.” Dr Montague explained. “I think the term ‘happy wheezer’ means the child is wheezy but the wheeze is not causing any respiratory embarrassment.”
“I wish the same could be said of you, Dr Dennis. I feel you are causing the profession a great deal of respiratory embarrassment.” Dr Morrison looked very pleased with himself when he said this and his two colleagues couldn’t supress large smiles.
“He was a perfectly happy child when he wasn’t wheezy, Dr Morrison,” my Dad rejoined. “I am afraid, if I cannot call him asthmatic, I am going to have to call him an unhappy wheezer.”
“These so called asthmatic or wheezy children are invariably well with completely clear chests when we do see them in the clinic,” said Dr Montague. “I sometimes think that our colleagues in general practice have rather vivid imaginations.”
“The trouble with asthma,” my Dad said, “is that the symptoms and signs come and go. If one of my patients is wheezy, they can pop down and see me on the very same day or, if I am unexpectedly busy, on the next day. They may wait 6 to 12 months for an appointment in the paediatric clinic. Who knows if a patient is going to be wheezy in September, next year. If I remember, little Phillip was a lot better with his brown inhaler. He became a happy little boy who did not wheeze.”

“I think we have heard enough, Dr Dennis.” Professor Mortimer spoke impatiently. “It troubles me that, in addition to the fact that you have made at least five diagnoses of asthma on rather flimsy grounds, you don’t seem willing to learn from our experts.”
“I really don’t . . .”
“I am afraid that we need to draw the proceedings to a close, Dr Dennis”, Professor Mortimer interrupted. “We have all got more important matters to deal with. Our unanimous recommendation is that you should be banned from making a diagnosis of asthma in either adults or children for the next 3 years. You should, on no account, initiate a prescription for an expensive, preventative inhaler without the patient being assessed by an appropriate specialist. We also recommend that you should undergo intensive training on the use and interpretation of spirometry. Any breach of our recommendations could lead to a hefty fine and a temporary period of suspension from your practice.

An irresponsible diagnosis of asthma.