The experts are changing their minds again, but Copperfield has decided he's not going to take any notice of them
Plus ça change, plus c'est la même chose. For the less Gallically gifted, that's translates as: ‘Holy shit, when will the powers-that-be make up their minds about anything and leave us to practise as we think fit, which was usually fine in the first place – I'd really love to shove those precious guidelines up their stupid fat bottoms?'
Look. After a great effort of will, much persuasion from my more ‘progressive' partners and some stick-wielding from those who use rolled-up NICE guidance as, well, a stick, I finally managed to memorise the ACD rules. True, the lack of a B threw me, as did the fact that amlodipine, a C, begins with an A. But, even with a mystifying lack of QOF points to play for, my determination eventually won through.
I shouldn't have bothered. Because I've just discovered that ACD is going in the BIN. Apparently, cutting-edge cardiologists now reckon we should be scattergunning our hypertensives with triple drug combos from the off. And it gets worse. Averaging out the systolic is suddenly Mesozoic medicine: blood pressure variability is the thing. That and highest systolic. So those systolic ABPM outliers I've always happily ignored really are about to blow the patient's head off. And the white-coat effect is actually the black cloak of the Grim Cardiovascular Reaper.
Bollocks. That's 20 years' worth of careful hypertensive explanations and treatment down the toilet. Whereas the ill-informed old GP buffers who, much to our amusement, knee-jerk prescribed Tenoretic K, or whatever, on the basis of a one-off dodgy systolic, had it spot on.
Conclusion? Everything we know is wrong. And what we thought was wrong is probably right. For Chrissakes. What next? HRT for the menopausal masses? Strict bed-rest for back pain? Thalidomide for pregnant mums?
Hang on, though. What about EBM? Isn't it supposed to rescue us from all this paradox and confusion? That's what the movers and shakers would have us believe, as they move and shake their latest dogma. But EBM changes its mind more often than a two-year-old in a sweet shop. Think aspirin and primary cardiovascular prevention: one week it makes you live forever, the next it makes you bleed to death. And think, too, of the recent clopidogrel-PPI warning, which was an official scare for as long as it took me to type that sentence. And diabetes? Yesterday, really tight control was good, today it's bad, and tomorrow, who knows, it'll be ugly.
The result is that medicine is increasingly like a game of musical chairs conducted by those with loud voices and arrogant certainty. But while those around me dance frenetically as po-faced, Clinical Evidence-waving academics call the tune, I'll adopt the approach of masterly inactivity: I'll do nothing. I'll ignore the carrots and sticks persuading me to follow this guidance, prescribe that drug or jump through the other QOF hoop.
Because I know that, when the music stops, everything will be exactly as it was and I'll be able to carry on just as before. In other words, I'll be left with a great sense of déjà vu – or whatever that is in French.
Copperfield
