Q I often consult quick reference guidelines during a consultation. What are the pros and cons of discussing the guidelines with the patient?
A In these politically correct times, we tend to accept without question the idea that everything should be discussed with patients.
The reality, of course, is that there is very limited time for a consultation and time must be used to best effect. This may or may not mean discussing guidelines with the patient.
What are the arguments? There is the general principle that the better the patient understands the treatment, the more likely he/she is to comply intelligently with it.
On the other hand, there are a number of things, as well as lack of time, that might be said against discussing a guideline.
- The patient may not need a discussion of the guideline because he/she is not interested, or is quite happy with what is proposed.
- You may consider that the patient is not able to absorb the information or make sense of it.
Taking the patient through a guideline may complicate a consultation to no good purpose and may worry the patient, if only by suggesting that there is more to be thought about than is apparent. It is easy to forget that knowledge can be burdensome as well as liberating.
In general, it is important to make sure that patients understand enough both to satisfy their curiosity and to participate fully in treatment. This will usually not involve discussing a guideline, even if you consult the computer on your desk.
The situation is different if patients come into the surgery with details of a guideline that they have found on the internet, or if they have heard something that contradicts the advice you wish to give them, or they are anxious for reassurance. Here, referring to the 'expert authority' of a guideline may help.
Q We have been using a practice protocol for managing patients with coronary heart disease for some time, and now our PCG has developed a different protocol. Are we obliged to change our approach?
A The short answer is no – you are not obliged to change your approach. Your practice is under no obligation to adopt a PCG protocol, or to apply it to any or all patients.
However, it is worth considering the differences between your practice protocol and the PCG protocol.
It may be that the differences simply reflect a different way of organising the information or the work. If this is the case, it may be helpful to speak to the doctor who leads PCG guideline and protocol development, with a view to agreeing with the PCG that, since your protocol is essentially the same as the PCG protocol and is already operating successfully in your practice, you can continue with your way of doing things while remaining fully committed to working with the PCG on this – and other – matters.
If the differences between your protocol and the PCG protocol are important clinically, you should establish why the PCG has come to a different conclusion.
It may be that there has been new evidence since you drew up your protocol. Their background work may have been more thorough than yours, perhaps because they had access to more resources than you, and you may conclude that their protocol is better.
On the other hand, you may feel that your protocol is better than the PCG's protocol, in which case I would encourage you to take the matter up with the PCG and seek to persuade them that their proposed protocol is not as good as it could be.
In general, it is a good idea for all practices in a PCG to sing from the same hymn sheet, unless there are good reasons for them to go their own way.
Using common protocols is helpful when conducting clinical audit or comparing performance measures, and when patients transfer from one practice to another within the PCG.
Q Where can I get advice on drawing up practice protocols? Are there any basic rules that we should be following, or any pitfalls to avoid?
A Drawing up practice protocols is an art rather than a science. The rules to follow have been described in past issues of Guidelines in Practice particularly in the series entitled 'Tips on guideline use' (January to December 1999). Articles in this series contain a number of references to specific sources of information.
The basic rules are:
- Don't invent your own protocol without very good reason
- If a protocol doesn't exist for a subject of interest, start by assuming that there may be hidden problems in the evidence
- Only develop (or introduce) a protocol if the subject is obviously important to the patients and/or the practice
- Base the protocol on evidence
- Involve all potential users of the protocol in drawing it up
- Test the protocol to make sure that it works in your practice
- Give one person the responsibility and authority to keep track of how the protocol is working.
If you want help and advice in drawing up a protocol, try one or more of the following:
- Other GPs within your PCG or neighbouring PCGs
- The RCGP
- The Clinical Governance R&D unit in Leicester
- The National Primary Care Research and Development Centre.
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