Wednesday, 14 March 2012

Guidelines are not rules

The practice of medicine is overwhelmed by guidelines.

Today I received a mildly assertive letter from a local hospital consultant who wanted to know why a patient had not been assessed 'according to the guidelines'.  I guess if such a consultant was to spend a day sitting in with me at the surgery I may well have to do a fair amount of explaining-deviating from guidelines as I sometimes do.

For me it all comes down to the practice of medicine as an art. Yes it's important to be aware of guidelines. After all they have generally been prepared by a group of experienced clinicians. But guidelines just do not allow for the unique individuality of each patient and each doctor.  Consider,

1. Each patient is one patient! Guidelines are based upon populations.
2. Each patient has a unique context in terms of, attitude towards medication, motivation to engage in treatment, age and comorbidity, medication which is already being taken etc.
3. Over a long career the doctor becomes attuned to particular drugs and their side effects, and knows what to ask during follow up with reference to side effects. Prescribing unfamiliar drugs, even though they may be recommended in the guidelines,  may not be best in the context of the exclusive relationship existing between one doctor and one patient.
4. A too rigid approach to investigation and treatment of each patient doesn't allow for the clinical instinct of the doctor, the tacit knowledge gained from experience which is hard to explain and even harder to teach.

Learning medicine is a life-long pursuit. It's a shame that just when you feel you're getting the hang of it, retirement looms!
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