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A faulty production line

GPs must put protocols in their proper place

Dr Rebecca Jones argues that medical scores and toolkits cannot replace intuition

Medicine has its basis in science, but its practice is an art. We are taught the basic disciplines of anatomy, physiology, pharmacology, pathology, even communication skills, but the way in which these skills are put together and performed is tailored by the individual practitioner to the individual patient.

GPs have developed a tool that is far more powerful than any calculator or protocol – intuition

So why are GPs being inundated with clinical tools and calculators that only allow us to work with limited autonomy? Such protocols are embraced by our guardians and regulators, but can be a source of frustration for many doctors.

Take the recent guidance telling GPs to use tools to identify sepsis. It starts with a definition of sepsis, which is reiterated later on – an insult to GPs who have studied and trained for many years and who need no clarification on the definition of sepsis, or to be told that the most vulnerable are children, the elderly and the immunosuppressed.

The toolkit defines systemic inflammatory response syndrome (SIRS) for GPs, but I find it difficult to believe that any doctor, let alone a qualified GP, needs to be informed that tachycardia, pyrexia and tachypnoea indicates that a patient is unwell with potential sepsis. It describes a ‘novel concept’ of red flag sepsis, but for a GP, there should be nothing novel about such an assessment. The toolkit goes on to define the severity of sepsis, but an admission is made that much of what is included is irrelevant in primary care, again raising questions about the necessity for such a tool for GPs.

So why are such protocols being pushed on us? Perhaps the most obvious answer is that care needs to be standardised, especially since an individual GP can now be paraded in the media for making a mistake. But at what cost? Whispers have been creeping around that the Government has intentions of filling the voids in staffing with lesser qualified professionals who are cheaper to train and employ. Surely such individuals would need a set of tools and calculators to practise safely?

The gut feeling

GPs have developed a tool that is far more powerful than any calculator or protocol – intuition. Recent cancer guidelines relay in fine detail what needs to be referred via the fast-track pathway. What they don’t tell us is ‘Refer urgently if you just have that gut feeling’, and the QCancer tool adds little to enhance your assessment of a patient. Unfortunately, in a world of evidence-based practice, intuition doesn’t hold much weight, and is certainly something that we would not be able to standardise. And perhaps many GPs wouldn’t be happy with the level of risk that comes with using softer tools such as intuition rather than Government-led protocols. Maybe the level of risk in practising medicine is just too high these days, and ignoring gut feelings and using official guidance allows us to comfortably manage this. The caustic medicolegal climate is one factor pressing doctors into using these tools and not trusting their experience and training. But in a specialty where you come to know your patients and their families intimately over many years, intuition can be more powerful than a clinical tool. One of the joys of medicine is experiencing the individual conundrum that is each and every patient, with their differing presentations, and the satisfaction of arriving at a diagnosis.

You cannot turn medicine into a tick-box process. Nor should you teach your grandmother to suck eggs. GPs have trained for many years to gain the knowledge and skills that we work with, and what GP would feel respected and satisfied if all we had to do was ask a few questions and follow a flow diagram to the diagnosis and management plan?

I am not against all tools – in fact some prove invaluable, such as CHA2D2-VASc and ABCD2. However, it is the sheer number of them that runs the risk of rendering our learned skills redundant.

So what is the answer? Perhaps we need guidelines, calculators and tools to be created with respect to the doctors who will be using them, and a realisation that secondary care protocols may not be relevant or appropriate in primary care, and vice versa. Relevant protocols could be reviewed by GPs who will be using them, allowing them to feed back their feasibility to those developing them.

Or perhaps the art will be in finding the balance between the use of these clinical tools and our own intuition.

Dr Rebecca Jones is a GP in Hastings, East Sussex, and trainee/NQGP Representative for GP Survival


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Readers' comments (15)

  • The problem is that all jobs, not just health workers, have been broken down to itemised, coded procedures each with its own protocol. There are not many 'generalists' left like GPs in other sectors. Look at the development of patient held budgets for specific parts of health care delivery.

    One of my patients is an old-time car mechanic who looks back in fondness to the days when a customer brought in a vehicle and he didn't have to put it on the computer. He used his intuition to diagnose the problem and actually mended the part that was wrong rather than bolting off and bolting on the new or recondition part. Sadly the job that the GP seems to be going the same way.

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  • Protocols are being created to enable less qualified staff to replace GPs.

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  • I agree that these have a role. What is silly is that a clearly depressed or anxious patient needs to score phq....
    These change within the hour and we are fools to rely on these .

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  • We and all of our patients experience life in an analogue way, but the powers that be can only record digitally. Read just one of the descriptive pages from Charles Dickens. How could you put that into a digital form? There in lies the problem.

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  • Guidelines are useful for novices. One of the early projects looking at decision support systems (for abdominal pain) showed that practitioners in their first few months made better decisions using the tool - and also that they learned more quickly through using the tool; but after a fairly short time the tool became redundant.

    The same applies to many guidelines - they are most useful for uncommon things you see rarely. But identifying the well/ill child correctly is a core GP skill.

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  • Intuition has a greater ppv than many cancer related symptoms....some evidence for this bit which nice ignored

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  • It is a poor substitute for experience and the more you practise medicine the more you learn to intuitively recognise conditions.Helpful to young but a way of demoting the skills of older GPs.
    This was recognised previously in seniority pay and at each stage I felt I had earned it.
    Retired GP.

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  • This piece is particularly prescient in this day and age. So many practitioners seem to treat Guidelines as Rules, and follow them slavishly, even when their intuition says differently.

    So many bureaucrats and administrators insist on it, and are critical if the letter of the Guideline is not followed, even if they do not understand the process.

    Two sayings come to mind. Firstly, the principles by which the GMC are (used to be?) guided are to invite us to "Comply, or explain". I would never have had a problem explaining my actions.

    Secondly, "Rules are for the obedience of fools, and the guidance of wise men". Perhaps it is worth recollecting that we used to be the wise men, and maybe we should not be shy about returning to that status.

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  • simple objective tools are being increasingly introduced. They are testing ground for apps instead of real GP

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  • I can give an alternative perspective to many comments here.

    Anonymous | GP Partner24 Mar 2016 12:03pm
    Since my husband was specialised in engine tuning and diagnostics from the early 80's, one of his frustrations were old time mechanics thinking they could "tune by ear". Often, when husband had connected his gas analyser and/or ECU analyser, it was found the "by ear" tuning was actually compensating for a fault somewhere else that could cause damage later on. For example, "swinging the timing" to stop pinking which covered up increasingly carboned up valve seats that would burn out if not set to the right mixture.

    Anonymous | GP Partner25 Mar 2016 5:47am

    "I agree that these have a role. What is silly is that a clearly depressed or anxious patient needs to score phq...."

    ...actually...I was severely clinically depressed for around 5 years but didn't realise how bad I was until I thought the same as you, but decided to fill in a PHQ-9 form on myself. I was shocked to see how bad I was!
    A year later, even though I still had very bad days, it was helpful to see my score had dropped from 27 to 15, then 6 months later down to 7.

    Last, and the other discussing protocols and guidelines. In nursing they are not the same.
    A protocol is more of an algorithm so you don't leave something out, whereas a guideline is only a guide.

    As a nurse I get even more frustrated by protocols at times, but as a colleague of GPs, I do observe that they, the GPs, can miss out crucial simple things because they use protocol less than a nurse.

    There is some evidence if you care to search, that shows this is why nurses can be better than GPs at QOF, because nurses tend to stick to templates because they are not medically trained. I wouldn't say it is because they are thick or uneducated though.

    It is in my view, a huge mistake to assume wisdom is relational to a medical degree. It might be relational to ego though?

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