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GPs must put protocols in their proper place



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