Tuesday, 28 August 2012

Guidelines or instinct in medicine?

When I first started in general practice there were no guidelines to clutter up the desk or the computer hard drive.  After some years, hypertension guidelines came along, but there were impossibly complicated and most ignored them. I recall about that time that I attended a GP study day which included a session on hypertension. A specialist in the field-Professor Peter Sever I believe if  I recall correctly-told us to ignore the complicated guidelines on offer and to simply buy a coffee mug with the numbers 150/90 inscribed on it!

I thought about this today when I was chatting to a delightful man whose wife I had seen recently. She had unfortunately had a stroke just a few days after she had consulted me, with possibly new onset atrial fibrillation (it was picked up routinely so it's impossible to know when it started).  I particulalry recalled seeing her,  since I had carefully searched for the latest guidelines and calculated her CHADS2 risk score. All of which led to a very low risk number for her and no prescription of Warfarin. On reflection I wish I had prescribed it, and yet who knows whether it would have made any difference.

I've not been a big fan of slavishly following guidelines since they feel by nature, very wooden, and seem to take little regard for nous/intuition/experience/tacit knowledge-or call it what you will. However I realise that guidelines are there to guide and will generally provide the best advice for each patient,  based upon multiple studies involving many people.  But the person I am treating is an individual-and that is the nub of the problem. How do I know that the person in front of me will behave in the way that most (but by no means, all) of the patients, who were recruited in the studies which form the basis if the guidance, behave. Or rather,  evidenced based medicine is a fine thing, but where are the evidenced based patients?

So what's the way forward? Truthfully I'm not sure. But I do feel that a practitioner who has reflected upon his practice over many years, and who has a reasonable awareness of current guidelines, will probably develop a degree of intuition, which enables him to make the best choices for the individual he is consulting at any one time. And this therefore favours long term relationships between doctor and patient-a feature which is noticeably being lost as more and more doctors move around between practices, and as more patients 'move around' and simply see whichever doctor is available.
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