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Protocols reduce general practice to Maoist collective

GPs' individualism is being eroded and their professionalism demeaned, says Dr James Sherifi.

General practice is in the throes of a cultural evolution which, although less dramatic than the Cultural Revolution in China in the 1970s, is just as momentous. Slowly and subtly, the individualism of the family doctor is being subsumed into the commune of practice en masse.

One of the many ways this is happening is through the doctrine of clinical governance and its philosophy of good practice – originally driven by guidelines but now, increasingly, by protocols.

The dictionary definition of protocol is ‘the plan for a course of medical treatment or for a scientific experiment'.

I have no problem with that. But somewhere along the road ‘plan' became ‘directive' – and that opened up a whole new can of worms because, from that point on, if you went off piste then you really were on medicolegal thin ice.

From a humble beginning in the management of dyspepsia in the 1990s, protocols have become ubiquitous. They have moved on to the management of a whole variety of conditions, from atrial fibrillation to venous thrombosis. But how useful are these really?

Among risk assessment and diagnostic protocols, the bar set for hospital referral is so low that the conclusion – in other words referral – is inevitable. Perhaps we should not be surprised by that, since most of these protocols originate in secondary care.

Low thresholds

For example, take the widely used CHADS2 for atrial fibrillation. You know, the one that informs the clinician whether warfarin should be used. Five criteria are assessed: congestive cardiac failure, hypertension, age (>75 years), diabetes and prior stroke or TIA (two points). The range of relative risk of stroke is surprisingly narrow, from 2% for a score of zero to 18% for

a maximum score of six. Yet the bar for warfarin anticoagulant treatment is set at score two (4%) or in some areas even one (2.8%). So the protocol is useless since, in practice, it is recommending that everyone with a new diagnosis of AF, apart from lone AF which accounts for less than 15% of all cases, should be on warfarin.

The same is true for the Wells criteria for diagnosing DVT, where the threshold for treatment is two to three points out of a maximum of nine. Apart from elaborately detailing the blindingly obvious (a feature common to all management criteria) it has a delightful get-out clause at the end – ‘another diagnosis likely = minus two'!

And don't even get me started on CENTOR for sore throats.

All these protocols have one thing in common – a demeaning of a GP's basic medical knowledge, a patronising implication that a GP is in constant need of guidance even for handling the most basic and common presentations.

Now a new set of protocols has been introduced governing referral letters to the point where a referral can be rejected for not detailing a BMI or recent HbA1c. Nuanced letters, so important to transmit important subtext in this open-access society of ours, are no longer tolerated. Referrals have literally become a tick-box form. And we haven't even begun to unleash the Little Red Book as clinical commissioning groups progress with their inevitable collectivisation of the hapless GP.

So what started off as a useful tool to benefit patients has now taken on a rigid inflexibility that benefits no one, except a legion of auditors employed to police compliance. GPs are no longer trusted to make clinical decisions in a holistic manner relevant to the patient in front of them, but instead have to subsume their experience to that of meta-analytical studies.

In an arguably imprecise science such as general practice, heaven help doctors who do not follow protocol, because they certainly won't get any support from their medical defence society.

And for those who question the march of the protocol? Rather like the Cultural Revolution in China, they can only expect to have derision heaped upon their heads – for now we are truly in the grip of ‘dictatorship of the protocolariat'.

Dr James Sherifi is a GP in Colchester, Essex