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Medicine by numbers

You can paint the Mona Lisa, The Girl with the Pearl Earring or Guernica: all you need is a ‘Painting by Numbers’ kit. These were very popular when I was a boy, and I could paint them although I had no talent in art.

However, a masterpiece cannot be replicated, and efforts by amateurs merely emphasise the excellence of the original.

Medicine, once considered an art, is becoming increasingly governed by the same processes used in these kits. One particular tyranny in modern medicine is the development of guidelines. I have, for many years, been deeply cynical about the value of these documents. While I am not antagonistic to the sharing of good practice, I see the development of guidelines as a pernicious thing.

There are four reasons. First, the blind acceptance that guidelines outline the ‘only way’ of doing things. I have been around long enough to have one set of guidelines, which have been contradicted later by another set. For instance, back pain was treated with complete bed rest on a hard surface until around 25 years ago. Not any more.

The second problem is guidelines just aren’t very helpful. I can remember being asked to look at an early draft of the Map of Medicine, an algorithmic attempt to give us decision-helping tools. Simple things like the management of thyrotoxicosis, for example, were covered reasonably well but the real value was the management-aiding algorithm. The Map had little value in the actual diagnosis of the condition. I couldn’t find a section that explained what to do when a patient said, ‘I’ve got a swimmy head, doctor’, or, ‘I was fine when I woke up in the morning, but by lunchtime I was bollocksed’. The Map of Medicine remained unused, being about as much value as the 13th-century ‘Mappa Mundi’ in Hereford Cathedral.

Third, and possibly most perniciously, guidelines can be used by a raft of unqualified people who want to play at being a GP. Multiple examples of this process have occurred since the out-of-hours services were privatised, dumbed down and ‘algorithmed’. One of the things I have to remind my trainees is that guidelines are more a recommendation of good practice, rather than an instruction manual.

Young doctors are taught to over-rely on guidelines, and this results in ‘medicine by numbers’. Their history-taking is rudimentary and examination cursory. It is all about pigeon-holing conditions, so there is ‘a chest pain’ in Cubicle Four, rather than a 45-year-old man with chest pain. Once someone with chest pain is diagnosed as such, they are on the conveyor belt. All clinical decisions are based on tests like Troponin-1.

Fourthly, and most worryingly, guidelines are used to legislate our decision-making. I can see a smart-suited barrister having a good time asking a doctor why they didn’t follow the guidelines, despite the fact that many GPs feel that guidelines are of little value and, at worst, contradict one another. I don’t spend much time following guidelines. I don’t think they are of much help.

The Jobbing Doctor is a GP in a deprived urban area of England