PI Brief Update

Red Flags: A Guide for Lawyers - Dr Mark Burgin

12/06/24. Dr Mark Burgin considers the controversial topic of Red Flags and how they can describe how doctors use the clinical process.

In many cases the concept of Red Flags becomes a battle ground with one side arguing that they do not exist and the other that they are an essential part of practice. The reality is that there is a responsible and reasonable body of opinion that does not use the concept. The medical leaders have not indicated which camp is correct and the GMC has not offered guidance.

Red Flags are a commonsense way of expressing the factors that both doctor and patient agree are worrying. Doctors who refuse to accept that a patient has a worrying issue can make the patient feel that their problem is being dismissed and fobbed off. On the other hand, patients may not like the phrase Red Flags and prefer a different description.

Some doctors use the term Red Flags in a limited and counter intuitive way. They will say ‘chest pain, shortness of breath, no red flags’. This makes no sense as both chest pain and shortness of breath are Red Flags. Before we explore why some doctors dislike the concept, we should consider how they should be used.

How to Use Red Flags

Red Flags are any aspect of a patient’s experience that points to a possible serious diagnosis. Symptoms and signs that commonly occur with serious diseases such as bleeding and pain should be considered as Red Flag symptoms and signs. A Red Flag risk factor is one that is significantly abnormal such as morbid obesity or high-risk levels of cholesterol. They are Red Flag because they could be the first sign of a disease such as atherosclerosis.

The purpose of Red Flags is to warn the doctor that they need to take more care with this patient. The Red Flag directs the doctor’s attention to the possibility of a particular disease and encourages them to explore further. This can be through further questioning of the nature of the Red Flag e.g. what type of chest pain, is it related to exercise or food?

Making Red Flags safe is a primary task in a clinical setting. whatever it is called, the doctor should explain each Red Flag so that it is no longer warning of danger. This is usually by recognising the pattern as coming from another problem. Sometimes examination, tests or even referrals are required if they remain unreassuring.

Checking that all the Red Flags have been dealt with is useful housekeeping at the end of the consultation. This can be shared with the patient by explaining why they think that the heartburn is due to acid rather than a heart attack. This empowers the patient to return if the pattern changes and becomes more concerning.

Why do some doctors dislike the concept of a Red Flag?

The difficulty with Red Flags is that they are present in most consultations. There are few people who do not have an abnormal risk factor or a worrying symptom. In fact, most people attend doctors precisely because they are concerned about missing a serious disease. Some doctors find the concept of Red Flags distracting because they are already assessing the patient for serious disease.

The time taken to consider Red Flags is usually minimal because it is already part of the best doctor’s practice. Good doctors already think about the possibility of serious disease and consider the differential although may use different words. Empowering patients to understand their symptoms does require confidence and some time but is worthwhile in time saved later.

Some doctors are anxious about missing Red Flags so they try not to think about the concept. These doctors can find managing uncertainty challenging and prefer instead to either ignore or refer. The problem is not about the words used but understanding risk. There is training available to allow doctors to develop strategies to overcome these issues but it also is important that they have good support from a supervisor.

Finding a common ground

The expert should acknowledge that there is a range of opinion with some doctors using different ways of describing the Red Flag factors. As long as the doctor has covered all the Red Flags in their records it does not matter what they call it. If however, a doctor fails to record asking questions about a worrying factor then they are likely to be criticised.

A person vomiting blood should have a record about abdominal pain because it is basic medical training but also common sense. The judge will not accept failing to ask about associated symptoms, because they expect the doctor to do this. An expert who tries to argue that a reasonable doctor would not consider pain and bleeding are linked will lose credibility.

Another problem is when the doctor has not recorded the problem in enough depth. A Red Flag diagnosis such as early onset COPD needs explanation because it is potentially life limiting. Whether the doctor uses those words they should check that the diagnosis has been made properly and other lung diseases have been ruled out.

Conclusions

All experts whether they believe in Red Flags or not should agree that a doctor should pay attention to factors associated with serious illness. They should agree that a person with high cardiovascular risk factors needs management to reduce their risk. A person with chronic diseases should be monitored for complications when repeat prescriptions are given.

The responsibility for assessing the patient’s Red Flags has been moving from the doctor to the patient as doctors have less time. Patients are increasingly complaining about not having time to tell the doctor all their concerns. They may say to the expert that they told the doctor about Red Flags which were ignored.

Red Flags remains a useful shorthand for worrying factors that need the doctor’s attention. Where the expert does not like to use the term Red Flags the lawyer can ask them how they describe these factors. Some experts are happier using phrases like worrying symptoms, high risk factors or indicators needing further investigation.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

This is part of a series of articles by Dr. Mark Burgin. The opinions expressed in this article are the author's own, not those of Law Brief Publishing Ltd, and are not necessarily commensurate with general legal or medico-legal expert consensus of opinion and/or literature. Any medical content is not exhaustive but at a level for the non-medical reader to understand.

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