Thursday, 1 April 2010

Common drugs, rare problems and protocol free solutions.

One of the current joys of general practice, for those of us here at ND Central who have a scientific medical background, is that you are (still) allowed to practice medicine scientifically rather than by protocol.

We apologize for banging on re protocols but every staff member here is sick of NHS and local Politburo protocols increasing their workload but delivering bugger all real healthcare.

This privilege is being increasingly eroded by the actions of the Thickerazzi who feel that all humans are created equally thick, as they are all failed Einsteins, and can only do things by reading from a script usually prepared for them by those just fractionally brighter than they are.

In this way they hope to control, in a Russian Soviet style which they have not yet noticeed failed 20 years+ ago, what everyone does in medicine and bring it down to the lowest common denominator of intellect, that of your average PCT Chief Executive.

They hope that the Thick will truly inherit the Earth for they perceive that they will run it for the betterment of us all (into the ground).

A delusion is sometimes defined as a belief in the absence of reality.

Under the current policy of care in the community for the mentally ill, all those who suffer from permanent delusions of grandeur and misplaced ability are now employed by PCTs and the Department of Health and remarkably get paid, sometimes huge salaries, while they have their “treatment”.

If you think that anyone here at ND Central can rustle up a mitre joint or service a jet engine after reading a set of laminated protocols over lunch then think again.

We know we cannot.

We know that real professionals need training, knowledge, ability and skill. Some of these attributes you may acquire by birth and genetics but most of which you will acquire by education, practice and experience.

We, as doctors, would not like to even attempt the tasks above as we prefer to practice safe medicine not cheap laminated protocol moron medicine. We know our limitations and this is important which is why we are not joiners or jet engine technicians.

For there are old pilots, and there are bold pilots but there are no old, bold pilots in aviation and good pilots like the fact that the number of their takeoffs hopefully equals their number of landings. The reason there are no bold, old pilots in aviation is that these pilots eventually crash and burn.

Rather like politicians reforming the NHS. Nothing useful achieved, like a landing, just a huge pile of burning wreckage which they always walk away from Scot free unlike anyone flying a plane or managing a patient where you are accountable either via a death or the loss of your career.

We are doctors whose skills take many years to learn and are not acquired by the reading of a laminated protocol. They are based on a core of knowledge acquired at medical school, refined when you start learning medicine for real as a junior doctor who is guided by those more senior and experienced and (hopefully) refined from every patient you see and learn from.

Not an A4 laminated sheet of paper.

We respect other peoples’ acquisition of skills and those of us who were crap at metalwork at school, but who excelled at technical drawing, realize that there are horses for courses.

The scientific approach is that you devise a theory, or “hypothesis”, devise an “experiment” to prove or disapprove it and revise the theory on the basis of the experiment a “conclusion”.

If the theory is correct then subsequent repeats of the experiment should lead to fairly consistent results.

A recent consultation led us to think about how the protocol driven inferiorocracy, that is the current NHS, would have coped with a set of atypical symptoms.

We would love to have had access to the ultimate inferiorocracy, the NHS (re)Direct computer system but we do not have. We cannot, therefore, test this one on the ultimate of ZaNu Labour’s dumbed down protocols and see how it would have coped.

We could, however, guess the outcome.

The symptom with which we were presented with was:

I clean my nose with a toilet brush each morning but in the afternoon I use a toothbrush. The rest of the time I am fine”.

Now as some of the most inferiorly educated members of UK society called doctors, whom we hope, and pray, are not as yet, soley QOF orientated, protocol box ticking morons this symptom got us thinking.

We thought, as any intelligent member of society would have, we have not got a clue what this means.

So we went back to basic training. We did as we were taught at medical school.

We took a full history, examined the patient and arranged a basic set of blood investigations.

However, we were still puzzled by this set of symptoms. We had in decades of collective practice never seen, or heard of, this set of symptoms either, as an individual or, collectively as a team.

Our taking of a history, combined with a review of medication, suggested a remotely possible, but a highly unlikely, cause for our patient’s symptoms.

There was a very small chance that this might be the cause and so, before the blood tests were done, we suggested a possible “hypothesis”.

We asked the patient to perform an “experiment” and stop taking a medication they were on even though they were taking a homeopathic dose of this commonly used drug.

When the patient returned all the tests were normal. More importantly so was the patient.

Our educated guess, combined with our scientific approach, had produced in less than a week of waiting for test results a result, a “conclusion”.

No further unnecessary tests or referrals were required although we were thinking should we refer the patient to a neurologist (as a possible brain tumor) or a psychiatrist in case their symptom was a sign of severe mental illness.

We do wonder how many other such “experiments” are performed each week in UK general practice? And more importantly how many of these are successful, cheap, protocol free, test free “experiments” result in a successful outcome (“conclusion”)?

And how do they compare with protocols followed by other “scientists” employed by the likes of NHS (re) Direct?

The same morning we did this “experiment” we did a whole surgery and did not follow a single NHS protocol.

If you are a properly qualified doctor you have to formulate a “hypothesis” each time you see a patient. Sometimes this is called a differential diagnosis, or in other words, your symptoms might be this or this or this.

This process of science in the NHS in general practice involves as little risk to the patient as possible but gives the maximum return to you as a doctor in terms of minimal diagnostic expenditure (to the State) to get a diagnosis as quickly, and as cheaply, as possible.

As a doctor you have to think about how to prove or disprove your theory and devise an experiment.

This is a summary of what your average UK GP does most of the time they see you.

It is not First World medicine, where the patient above would have had a brain scan and referral to see a psychiatrist and a neurologist ASAP for the remote chance that there would be something seriously wrong.

Common things are usually common in medicine, rare things are usually rare but not always so, but need to be looked for and considered with every patient for the price of (medical) freedom (to practice) is still eternal vigilance.

Experience does not give you all the answers as we learn all the time as GPs. And that is the point.

We should learn every time we see a patient and so slowly refine our practice (of the art) of medicine hopefully for the better.

Protocols stay the same, they do not learn from experience, as they are incapable of independent thought or learning.

Protocol driven medicine are the summaries of the thick as they try to break down a complex subject into something that they were incapable of understanding or doing but which they seek to control.

Praise be to the Party as they surely via reforms would have solved this problem so much more quickly, efficiently and cheaper than we could have ever have done?

Protocols. The future of medicine?

We hope not as they will miss, or dismiss, much more than they ever usefully achieve as those who use them will never think outside of the laminate.

At the moment we as doctors are still free to think. Let us hope that this freedom is preserved.

1 comment:

Anonymous said...

Right on - cheers for common sense.