Clinical guidelines – what's the point?
Well, clinical guidelines are systematically developed statements which assist clinicians and patients in making decisions about appropriate treatments for specific conditions.
Yes, I know all that bollocks.
Its not bollocks. A lot of good people sweat blood to put these things together.
I appreciate that. I just meant is anyone listening?
Why do you ask?
Why are you reflecting all the difficult questions back to me?
Because I'm a lecturer in communications skills.
Fine. Well, I'm a 70-year-old woman and so is my identical twin.
Well, she would be, wouldn't she?
Yes, but we also have the same angina.
Are you paying tribute to Benny Hill or do you suffer identical coronary artery insufficiency?
The latter. Anyway, for a long time we have patronised different doctors and have been amazed at how inconsistent they were when presented with identical patients with identical symptoms. One spends ages dissecting the precise nature of the pain, another prefers to talk about our cousin Ivan who is in secure accommodation. One GP stripped my sister from nipples to knees for a thorough examination, another tried to listen to my heart while I was wearing a donkey jacket. Often we leave with different diagnoses and different prescriptions. I thought medicine was a science. So why are we treated so non-identically?
Good question. Doctors like to attribute these glaring differences in performance to the art of medicine.
But that's my point. Aren't these guidelines you're churning out by the bucketful supposed to make sure doctors all think and do the same thing in the same situation?
In theory yes, but as you say there are thousands of the damn things and doctors differ in their ability to recall which drawer they put them in. So either you can't find any at all, or you end up treating angina with the irritable bowel guidelines. Also, remember that guidelines don't cover everything. Science won't tell you whether it's right or wrong for the doctor to ask after your cousin Ivan who's in secure accommodation.
Well I can. I think it's very thoughtful.
So good that my sister Elsie and I decided to go and see this identical doctor with our identical problems.
And what did you find?
He treated us differently.
On a Monday morning, Friday afternoon or after a night on call, he will never listen to our chests, explain his treatment or ask after Ivan. On a Tuesday, he will take our blood pressure spontaneously and on Wednesday we have to ask for it.
What about Thursday?
On Thursday, he makes us tea and shows us pictures of his children. If he's stressed he puts whisky in his. If he's very stressed he puts whisky in ours.
Well I'm sure he's just unusual.
No, he's not. I did a MEDLINE search. Look. BMJ, April 19, 1997. Do GPs act consistently when they meet the same patient twice?
Norwegian researchers sent two elderly female standardised patients (actors pretending to have angina in the same way) to 23 Trondheim GPs and found that the same doctor does different things to identical patients on different occasions.
Ah, but that's Norway, you see. It could never happen here.
And monkeys might fly out of my butt.
I'm afraid I'm going to have to ask you to leave now Mrs Simpson.
Yes, but just tell me this, doctor. Whatever happened to evidence-based medicine?
It never arrived. Good day.