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The joy of the irrational

Well, the Royal College Annual Conference has ended, and my brain is left buzzing with ideas, keynote messages, ambitions, anxieties (quite a few anxieties…) and dreams about the future of general practice. Oddly enough, though, there is one thought that keeps bubbling to the surface in the cognitive soup of my mind - out-competing the words of the many excellent high-profile speakers for my attention - and it came from a five minute presentation of a piece of research on the humble mole (the dermatological rather than mammalian variety).

Apart from being an excellent (and award-winning) piece of research, it gave an insight into the peculiar interaction that happens between the doctor and the patient, and the fact that, try as we might to rise above our weaknesses, we remain deeply irrational beings.

The study by Fiona Walter and her team evaluated the effectiveness of a piece of equipment called MoleMate, which is a non-invasive system for evaluating suspicious moles for the possibility of melanoma. The researchers compared the results of using a best-practice seven-point checklist alone, with the use of the seven-point checklist combined with MoleMate. The hypothesis was that the addition of MoleMate would reduce the number of unnecessary referrals by picking up a higher proportion of the significant lesions.

The results of the study in fact showed that MoleMate did not improve the appropriateness of referral, and was actually less efficient than best practice alone, since it resulted in significantly more referrals. So far, so good - let’s not bother to get this particular bit of kit for the practice, well we weren’t planning to anyway so no loss there. What is fascinating about the research, however, is the finding that both the doctor and the patient preferred the MoleMate arm of the research - they found it more reassuring to have the additional guidance of technology, even though the study found the outcome was better without the piece of kit.

I’ve been wrestling with this one ever since. The allure of technology grips many of us, and for some bizarre reason we often prefer to place our trust in the evaluation of a gadget made by fallible humans we can’t see, than the evaluation of the fallible human we can see. The obvious conclusion to this piece of research is to dispense with the machine, and yet we know that using the machine meant that people were more satisfied with their consultation and felt more reassured. If you had MoleMate sitting in the corner of your consulting room, therefore, would you be able to resist the temptation to reach for it from time to time to make your patients happier? It’s bad medicine of course, but then if your patients go away more reassured, is it really so bad?

In this instance I don’t think I could countenance using technology I don’t believe in, but it got me thinking about the things I do in the consultation which may not be so very different. For instance, I usually make a point of examining the head of someone suffering from headache. Except in rare circumstances, such as temporal arteritis, I know that my examination will make no difference to the outcome, but it just feels right to do it. When you have pain somewhere, you expect the doctor to assess where it hurts. I don’t want my patients to leave the consulting room feeling inadequately reassured, thinking to themselves: ‘he didn’t even look at my head’. And yet, if I know that my examination is, in a sense, a sham, as it won’t add anything to my assessment, in what way is this any better than MoleMate? Or, put another way, is MoleMate just a high-tech version of that ancient therapeutic act of doctors - the laying on of hands?

I don’t have the answers. I’m certainly not going to start recommending a new piece of equipment without a sound evidence-base behind it, but I’m strangely uplifted by the results of this study - because it is the unpredictable nature of the way we humans behave that keeps medicine interesting, and the complexity and challenge of communication between the doctor and patient that keeps me motivated.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68