The role of the GP in the care of people with haematological disorders
Many consultations in general practice involve haematological investigations. As a GP you should be able to:
- diagnose and manage haematological disorders, using history, examination, investigation, monitoring and referral where appropriate
- communicate effectively and consider symptoms that are within the range of normal or self-limiting illness and differentiate them from underlying pathology such as anaemia
- intervene urgently when patients present with emergencies related to haematological disorders
- coordinate care and collaborate with other organisations and members of the multidisciplinary team (MDT), leading to effective and appropriate acute and chronic management
- offer advice and support to patients, relatives and carers regarding prevention, prescribing, monitoring and self-management (for example, lifestyle interventions including diet, alcohol and drugs)
- know the epidemiology of common disorders and understand how to recognise them.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care prognosis.
Symptoms and signs of haematological disorders
- ‘B’ symptoms of lymphoma
- Bleeding, bruising, petechiae and purpura
- Bone pain or pathological fractures
- Deep vein thrombosis (DVT) or pulmonary embolism (PE)
- Fatigue
- Hyperviscosity symptoms (headache, visual loss, acute thrombosis)
- Jaundice secondary to haemolysis
- Lymphadenopathy, splenomegaly and hepatomegaly
- Pallor and anaemia
- Recurrent infection
- Recurrent miscarriage
- Skin manifestations of haematological disease (such as mycosis fungoides)
- Systemic manifestations of haematological disease (for example, sickle cell crisis)
- Weight loss
Common and important conditions
- Anaemia and its causes, including iron, folate and vitamin B12 deficiency, sideroblastic, haemolytic, chronic disease
- Anticoagulants: indications, initiation, management and reversal or withdrawal, including heparin, warfarin, direct oral anticoagulants such as dabigatran, drug interactions and contraindications
- Clotting disorders, including genetic causes such as haemophilia and Von Willebrand disease, infective causes such as meningococcal septicaemia and disseminated intravascular coagulation
- Common abnormalities of blood films and their management (for example, macrocytosis, microcytosis, spherocytosis, neutrophilia, lymphopenia, eosinophilia)
- Enlarged lymph nodes of any cause +/- splenomegaly, including infection and malignancy (both primary and secondary), management of a single enlarged lymph node
- Enzyme diseases such as glucose-6-phosphate dehydrogenase (G6PD) deficiency
- Gout associated with haematological malignancies and myelodysplasias
- Haematological malignancies such as acute and chronic leukaemias, lymphomas (including Hodgkin and non-Hodgkin lymphomas, gut and skin lymphomas), multiple myeloma
- Haemochromatosis
- Haemoglobinopathies such as thalassaemia, sickle cell disease
- Haemolytic diseases, including management of rhesus negative women in pregnancy, autoimmune and transfusion haemolysis
- Lymphatic disorders such as primary lymphoedema
- Myelodysplasia and aplastic anaemia
- Myeloproliferative disorders such as polycythaemia rubra vera, thrombocytosis
- Neutropenia: primary and secondary, including chemotherapy and drug-induced
- Pancytopenia and its causes
- Polycythaemia: primary and secondary such as hypoxia, malignancy
- Purpura: recognition and causes such as drug-induced, Henoch-Schönlein
- Splenectomy including functional asplenia
- Thrombocytosis and thrombocytopaenia, including causes and associations, indications for referral
Examinations and procedures
- Appropriately obtaining blood samples and requesting clearly selected and targeted tests with informed consent
- Use of near-patient testing for anticoagulation
Investigations
- Blood grouping such as ABO and rhesus status, including antenatal blood disorders
- Normal haematological parameters and interpretation of laboratory investigations such as full blood count, haematinics, monitoring of anticoagulants and investigation of coagulation disorders, including thrombophilia and excessive bleeding, protein electrophoreses, immunoglobulins
- Other relevant primary care investigations (for example, X-rays, ultrasound scans, paraprotein urine testing in myeloma)
- Relevant secondary care investigations such as bone marrow biopsy or aspirate, bone scans
- Antenatal screening for inherited haematological disorders (for example, thalassaemia, sickle cell).
Service issues
- Common investigations and treatment pathways in secondary care and referral criteria for common or important conditions
- Cancer care reviews and follow-up, including safe prescribing, management of multimorbidity and recognising signs of disease progression
- Indications for urgent referral to secondary care
- Pathology in other systems leading to haematological manifestations
- Certain services are highly specialised and regionally based, such as bone marrow transplant
- Appropriate understanding and use of shared care protocols linking primary and secondary care management
Additional important content
- Conditions with higher prevalence in certain ethnic groups (such as benign ethnic neutropenia, sickle cell anaemia, thalassaemia traits)
- Ethical issues related to blood transfusion
- Psychosocial impact of living with a haematological condition
- Major side effects of common treatments such as chemotherapy
Case discussion
Simon Chan, a 79-year-old man, presents with joint pains suggestive of osteoarthritis (OA), low mood and tiredness. His symptoms have been present for the preceding six months and appear stable. He complains of a poor sleep pattern and loss of appetite that appear to be depressive in nature. He lives at home with his wife and is otherwise in good health and active.
As part of routine investigations, his full blood count (FBC) has been reported as showing a raised lymphocyte count and flow cytometry suggestive of B-cell chronic lymphocytic leukaemia (CLL).
Referral to haematology was advised and a diagnosis of stage 0 CLL confirmed. No active intervention was recommended other than regular monitoring of Simon’s white cell count.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are the personal challenges I face in caring for chronic disease in older adults? How do my personal beliefs and attitudes influence the care that I provide? How do I balance my desire to give long-term personalised care with the risk of fatigue and burnout? |
An ethical approach This is about practicing ethically with integrity and respect for equality and diversity. | What factors influence the decision for active intervention in asymptomatic illness? How can I respect the autonomy of my patient in a scenario where decisions are based on technical clinical criteria? How do I ensure that timely access to care is equal to all? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | What are the challenges explaining a diagnosis of disease in the absence of directly attributable symptoms? How do I respond to the inherent uncertainties in future management? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How will I monitor this patient in the medium and long term? What information would require a change in current management? How do I balance the need for regular monitoring against over-investigation? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What might I have found on examination in this case? Without the blood test results, what might have been the differential diagnosis in this case? What clinical signs are the most sensitive and specific for haematological malignancy in primary care? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How can I incorporate shared decision-making in my management? What options are available to me if I am unsure what to do? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What clinical symptoms and signs would be considered ‘red flags’? What treatment options might be considered? How do I assess the need for or urgency of referral? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How does the diagnosis of CLL affect the assessment, diagnosis and clinical management of other potential comorbidities? What are the likely psychological and social consequences of the diagnosis of a long-term but as yet ‘untreated’ and currently stable disease? What are the most relevant uncertainties and risks? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | How will I coordinate ongoing care with the specialist MDTs? What factors might enhance or hinder the continuity of care? What are the best ways of communicating with very specialised teams such as haemato-oncology? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What do I know about the management of haematological malignancies? What are my personal educational needs that this scenario identifies? In what ways can I assess and improve the care of patients with indolent disease? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What shared care arrangements would I expect to be in place for this patient? How do I arrange ongoing monitoring at appropriate intervals? What support does the practice need to provide? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How do I differentiate and balance the physical and psychosocial symptoms of patients with chronic stable illness? How do I balance health anxiety with actual health risk? What other aspects of health promotion need to be addressed? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How common is this type of illness in my practice population? What support needs to be identified in my locality? What voluntary organisation might be able to offer support and resources? |
How to learn this area of practice
Work-based learning
Patients will present with various symptoms, at varying stages in the natural history of their illness. Discussion with a trainer will aid GP registrars in developing strategies to help in problem-solving. Supervised practice will also give GP registrars confidence. In particular, the GP registrar should be able to gain experience in the management of abnormal haematological findings as they present (incidental, acute and chronic), including emergencies. General practice is also the best place to learn about holistic chronic disease management (such as anticoagulation, anaemias, indolent malignancies, sickle cell disease and haemophilia).
Most GP training programmes have placements of varying lengths in general medicine, and some placements specifically in haematology. The acute setting is the place for you to learn about the immediate management of life-threatening presentations. As a GP registrar you will also learn about the interpretation of haematology lab results, and how to differentiate between significant abnormal findings and those of a coincidental nature, and appropriate secondary care investigations such as bone marrow aspirate and trephine. Outpatient or clinic settings are ideal places for seeing concentrated groups of patients with haematological problems. Your GP specialty training programme should offer you the opportunity to attend haematology clinics when working in other hospital posts, and you should also consider attending specialist clinics during your general practice-based placements.
Self-directed learning
There is a growing body of eLearning to help you consolidate and build on the knowledge you have gained in the workplace. You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare.
Learning with other healthcare professionals
Chronic disease management in primary care is a multidisciplinary activity. As a GP registrar it is important for you to gain an understanding of the follow-up of patients with haematological disorders even when the clinical lead is taken by secondary care or a community clinical nurse specialist. It is also important to understand the role of medical scientists and when it is appropriate to access their expertise in evaluating laboratory results.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Appropriate use of different anticoagulant therapies
- Interpretation of haematinic results
- Investigation of venous thromboembolism (VTE)
Simulated Consultation Assessment (SCA)
- A woman was investigated for tiredness and lethargy and has macrocytic anaemia and hypercholesterolaemia
- A child has developed purpuric rash on her legs (photo supplied) and had three days of mild abdominal and joint pains
- A teenager has had a persistent and worsening sore throat for five days and now has abdominal pain and lymphadenopathy
Workplace-based Assessment (WPBA)
- Case-based Discussion (CbD) on the management of a patient with persistent thrombocytopenia who is otherwise well
- Audit of the practice data on the appropriateness and value of requests for ‘routine’ haematology laboratory tests
- Learning log about the care of an elderly man who lives alone and has just been diagnosed with chronic lymphocytic leukaemia
- Clinical examination and procedural skills (CEPS) based on a patient with widespread lymphadenopathy