The mushrooming of protocols and guidelines has done little to improve general practice, says the Jobbing Doctor
People are people.
They are not a series of interconnecting biological systems that behave consistently. Managing in general practice is to deal with people as unique individuals (which they are).
When I was a young doctor, the way in which illnesses were managed depended quite a bit on using clinical judgement. You took a history, performed an examination and arranged investigations. With this information – like a three-cornered stool – you reached your diagnosis. Sometimes you only needed one part of this triad – the history of a myocardial infarction is fairly classical, or the appearance of shingles.
Then you managed the patient. Over the years I have seen the way in which patients are managed becoming much more rigid and formulaic. There are often very good examples of why this is appropriate, such as the UKALL protocols for managing acute lymphoblastic leukaemia: I remember following these as a young doctor at the Royal Marsden Hospital in the 1970s. This was appropriate, and we all bought into the protocol because it had been developed on the basis of consensus, collaboration and best evidence.
The mushrooming of protocols and guidelines has continued. Indeed we seem to have a protocol for every aspect of medicine, and they are creeping into general practice as well.
Doctors are different from nurses, and they perform different functions. The boundaries have been blurred in the last few years with the advent of the ‘nurse practitioner’. The authorities like nurse practitioners because they think that they are cheaper to employ, they stay in post for longer, and basically they will always behave in a predictable way professionally. In some roles this is an advantage – a nurse practitioner trained up to do routine endoscopies is fine for me. Having learnt how to do endoscopies myself as a junior doctor, and as a clinical assistant, I know that the first 100 you do are pretty poor.
Nurses aren’t doctors, however, and it is partly a factor of their intelligence (look at A-level results) and also their training: 10 years is the minimum for even the most callow and inexperienced of GPs. Nurses are good at following protocols and procedures – it reduces the need to assess the data, dip into your experience and knowledge, then apply it to the patient in question.
More and more of my patients are being followed up in the hospital sector by nurses and nurse practitioners. I know that because they send lots and lots of letters. They follow up patients assiduously and quite unnecessarily, and always follow the protocols. Religiously.
In an era of commissioning, one of the areas I will want to look at is the way in which patients are being managed in the hospital sector. I want my patients treated in hospital if there are procedures that I lack the facilities or ability to perform, or if I require the intellectual expertise of a specialist colleague. I do not want six-monthly follow-ups by junior doctors, and I certainly don’t want monthly follow-ups by a nurse. This is happening all the time now.
The argument advanced is that they are ‘just following guidelines’. This kind of clinical behaviour is intellectually very low-level: like a tram in the tramlines. Guidelines are of very limited value, often developed without much evidence, and applied uncritically.
The essence of a professional is that you look at all the evidence, decide what is appropriate having come to a view based on all the factors, and always consider the patient as your priority.
Too often they are used like a drunk uses a lamppost – for support and not illumination.
The Jobbing Doctor is a general practitioner in a deprived urban area of England.
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