I was interested to read the news item which suggested that taking patients' views into account has an impact on the treatment prescribed. While the study1 talked only about atrial fibrillation, it can be true in many other situations.
That is why I believe that prescribing policy has always needed a human touch. In this era of evidence-based medicine it has acquired even greater importance. 'Patients' treatment preferences may conflict with guidelines' is a headline shrieking to tell us something. The general public is indicating, perhaps, that cold science is what it dislikes about modern medicine.
Because of this lack of public support, we face a serious dilemma. I have visions of the prospect of arbitrary and unreasoning political and economic intervention in the medical care system. With the advent of clinical governance and NICE, the pressure on doctors to be scrupulously rational will grow. Rational means that the patient is the passive recipient of doctors' wisdom.
Realistic prescribing, on the other hand, ascribes considrable importance to the views of the patient, who thus becomes a partner in problem solving. A vital rapport is thus formed, and I believe compliance is improved.
It was once suggested that the downside of realistic prescribing is increased cost to the exchequer. But for those of us who have seen old people with 60 'brown inhalers' stacked in their cupboards, the most expensive medication is the one that remains in the bathroom, unused.
I submit that involving patients in disease management helps them to understand the need for treatment, and thereby enables them to consult us urgently when things go wrong.
The recent BMJ study suggested that guidelines for the management of atrial fibrillation should be modified to take into account patients' preferences in treatment decisions. I salute that. Strictly rational prescribing is seen as cold, unfeeling, rigidly concerned only with facts It is rightly viewed as unsympathetic and unappreciative of the person as a whole. Rational prescribing in the minds of our political paymasters is associated (rightly or wrongly, and that does not matter) with cheaper prescribing.
One of the exciting challenges of medicine, especially general practice, for me has been the reaching of decisions based on less than complete evidence. It is now difficult for me to think in clear, black-and-white terms.
My two sons, who work as junior hospital doctors, make diagnoses based on supportive positive findings of investigations. Treatment follows logically on from precise diagnosis. When patients die, the cause of death is confirmed at autopsy.
Real life in the community is, I dare say, different. By their very nature, conditions that commonly present tend to be imprecise and based on clinical assessment and interpretations. Much of the management and treatment of the patients is based on the opinion of individual doctors, which in turn is perhaps based partly on their personal experience.
In spite of PGEA, and the efforts of postgraduate institutes and tutors, there is a degree of professional isolation in general practice compared with the hospital environment. This naturally results in the formation of divergent views.
GPs operate in grey areas of medicine where it is possible and quite correct to hold polarised distinct opinions about prescribing for our patients. The essence of good care, in my opinion, is eternal flexibility and readiness to change long-held cherished opinions in order to allow a (reasonable) say from our patients.
I am not disputing the need or evidence-based medicine. I am still trying to find out for myself whether I should be rational or realistic. I feel as if I am still travelling. Perhaps general practice is all about travelling and not so much about arriving.
Dr Kausar Jafri, GP, Longton, Stoke-on-Trent
The more we create and rely on guidelines and protocols based on robust research evidence, the more our behaviour could be said to be scientific and measurable. There remains, however, a constant tension between the technical/rational model of medicine and the linical acumen model (science vs art).
A recent study1 and the comment it evoked2 looked at a formal and½repeatable way of involving patients in the clinical decisions being made about their care. The technique used empowers patients by better informing them about the relative risks of their condition and the alternative treatment options. It thus gives patients a more objective basis on which to make decisions.
The paper concluded that if elderly patients with atrial fibrillation were allowed to make an informed choice about their treatment, there would be fewer prescriptions for warfarin written than under guideline recommendations. It recommended a controlled trial on the use of decision analysis in the context of deciding whether to use anticoagulant treatment in patients with atrial fibrillation.
Where adequate evidence is available about a condition and the relevant treatment options, such a system could, in due course, be included in our clinical computer software. This might be particularly important where we delegate tasks to other members of the primary healthcare team.
Evidence of the patient's informed participation in the decision process is possibly most important when it goes against the guidelines.
The technique merely formalises a process that most of us go through every day. We are constantly trying to match the management of the condition or pathology in our textbooks with what will suit our patient.
Much of general practice fits into guidelines and mainstream practice, but one of the most important things a GP registrar learns in his/her year of training is the exceptions. These sometimes involve us in risk taking, and are nearly always brought about by the influence of the patient's views or situation.
There are times when it may be appropriate for the patient with acute renal failure not to embark on or continue with dialysis, for the patient with a carcinoma not to undergo curative chemotherapy, and for the patient with gastrointestinal haemorrhage not to be admitted to hospital.
There are also many much less critical cases where it may be appropriate not to adhere to a recommended pathway. We do not necessarily just agree with the patient's wishes, but they are an important part of the consultation, and we aim to arrive at an agreed plan after discussion.
There are many influences which may cause a patient to opt for an approach to his/her individual problem that is not consistent with guidelines based on evidence. It may even be that if these particular circumstances were to be reproduced in large enough numbers the evidence would support the patient's seemingly idiosyncratic way of approaching the decision.
This technique will be a welcome additional tool if it proves to be effective in further trials. It may result in the patient being more consistently and reliably informed where there is a sufficient body of evidence relating to a particular treatment decision.
The case for the art of medicine is strengthened by this research, which emphasises the need to talk to our patients, and involve them in the management of their own conditions. The art of medicine is not dead!
Dr Charles Sears, GP, Salisbury
If the recent news item on patients' treatment preferences, Dr Liam Smeeth cautions: "Good clinical practice can then be informed by the evidence; it may not always follow the evidence."
There is still a large groundswell of opinion among GPs against many clinical guidelines. I assume now that all clinical guidelines will be amended to take into account the 'fully informed' patients' views. If this does happen, I think many of those dissenting GPs will be happier to follow such guidelines – and that evidence-based medicine will have 'come of age'.
Dr Derek Jeary, GP, Ripon
- Protheroe J, Fahey T, Montgomery AA, Peters TJ. Br Med J 2000; 320: 1380-4.
- Smeeth L. Br Med J 2000; 320: 1384.