And so it begins! It has been months since I was contacted by one of the writers of the BBC’s increasingly popular daytime drama ‘Doctors’ who wanted to know about how Pernicious Anaemia affects patients. And yesterday saw the storyline about a patient with Pernicious Anaemia begin.
I don’t know why one of the writers contacted me, after all there is a qualified doctor who acts as an adviser to the show, but I remember being able to tell the caller that we were aware that many of our members waited many years for a correct diagnosis and that there were problems with the current test used to assess the patient’s B12 status. I remember also telling him that the range of symptoms was wide and varied and can lead to severe and irreversible nerve damage.
So – based on just one episode how accurate was the show’s depiction of diagnosing and treating PA?
Let’s start with the bad points. Firstly the doctor not only ordered a full blood count but also asked for the patient’s B12 and folate to be examined. That doesn’t always happen and actually runs contrary to NICE’s Clinical Knowledge Summary that states that B12 status in patients shouldn’t be assessed unless there is sign of enlarged red blood cells (macrocytosis). Still, there is some evidence that as the PAS raises awareness of the problems with patients receiving a quick and accurate diagnosis more and more primary care doctors are requesting the patients B12 and folate is assessed as well as the full blood count.
Secondly – the diagnosis and treatment. Well the doctor suspected anaemia due to the patient’s mucous membrane around her eyelids seemed pale which was a good thing, however we know that patients with B12 deficiency may not always have anaemia – a small but interesting point. And then there was the treatment – not a small interesting point but a large, very large piece of misinformation. The doctor told Stevie (let’s get familiar) that her treatment would be an injection every three months until her “blood returned to normal”. There was no mention of loading doses and of course, pernicious anaemia needs to be treated for life and NOT until the patient’s blood returns to normal. Surely the writers would know that B12 replacement therapy would have to be for life. Surely the doctor acting as medical adviser would know this and would have corrected the script. So what is going on? I think, and it’s only my theory – I have no inside knowledge – I think that the writers have deliberately written this huge error into the script to show how badly patients with PA are treated, will I hope that is what has happened – only time will tell.
And then there was the casual referral to a haematologist which only happens in the UK if the patient displays any neurological involvement. Now, Stevie has told the doctor that she has burning feet and prickly feet so the GP may have suspected neurological involvement but I don’t think so. I remember telling the writer that not all doctors make the link between neurological symptoms and B12 deficiency and I suspect that this may be part of the plot – that Stevie’s condition (and career) worsens before the link is made. If the doctor had suspected neurological damage then he should have prescribed an injection every other day until there was no further improvement.
Thirdly – the symptom of shortage of breath (or more accurately The Sighs). Was Stevie’s breathing problems due to shock or because of her Pernicious Anaemia? Had the writer exaggerated the problems that patients who have Pernicious Anaemia have in breathing normally or was her breathlessness due to her being in shock – that wasn’t made clear.
The Good Bits:
There were plenty of good bits. Firstly the acknowledgement that Pernicious Anaemia, if left undiagnosed and untreated can and does lead to mental disturbances – that was good. Secondly her erratic behaviour in the weeks previous to her being diagnosed was pointed out as was her forgetfulness – all strong indicators of PA. Then there was the tiredness and let’s remember that Stevie is in danger of seeing her business fold because of her incapacity to work – something that is much more common that is generally supposed. Another positive point is that Stevie is relatively young which runs contrary to what most medical professionals believe – that PA is mostly to be found in the elderly or very elderly.
Finally, one last but very good point – the laboratory telephoned the doctor just a few hours after Stevie had her blood taken to make him aware that the patient’s B12 level was dangerously low. The hospital laboratory that received my first blood tests did the same with my doctors.
The Future. So, as the plot unfolds and the story progresses what is going to happen? Will the doctor make the link between Stevie’s neurological issues and her PA? Will she manage perfectly well on an injection every three months? Will the doctor prescribe more frequent injections if she needs them? Will Stevie resort to alternative sources of the injections if he doesn’t? Will she make a full recovery or will she still be symptomatic for the rest of her life? We’ll have to keep watching!