Island reflections by Heather Currie

Holidays are for fun, relaxation, recharging the batteries, catching up, all things good. But holidays also give time to think and reflect and often holiday situations trigger a thought which may have relevance to a work situation. I think that’s ok, I don’t think I’m pathologically workaholic. I enjoy having time to reflect, whether that be on holiday or other.

heather-jettyA recent holiday in the beautiful west coast, triggered reflection on how we respond to patient’s needs, and perhaps how we could do better.

On the west coast of Mull is a ferry which goes to the tiny island of Ulva. While waiting to take a boat trip out to the Treshnish Isles (home of a huge colony of wonderful puffins), I noticed the sign indicating how to summon the ferry. No regular routine service, just a board with a moveable cover. Move the cover, red board shows, ferryman on Ulva sees red board, ferry sets out. Simples.. Ferry there when needed and when summoned. Receptive and responsive. It made me think whether or not we are receptive and responsive to our patients’ needs and what about the needs of the relatives?  A few examples make me think perhaps not enough?

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In recent times my mother in law sadly suffered from a stroke and was in an acute hospital for several months before being transferred to a Rehab unit and subsequently a nursing home. Being a patient is always a humbling and learning experience, as is being a relative and visitor of a patient. On one visit I was concerned that her finger nails were quite long and dirty. “Mum” could not speak at this stage but since she was always very particular about her appearance, I knew that this would cause her distress and asked the nurse in charge if it was at all possible, please please, thank-you so much…(it felt like asking for anything was a major challenge) could her nails be cut. To my surprise and disappointment, I was told that this was not possible since only two nurses on the ward had had the “training” and when they were on duty it was unlikely that they would have time. Receptive and responsive or too rigidly bound up in rules and protocols of questionable evidence base that basic needs are not met? Thereafter we took it upon ourselves to cut the nails ourselves!

I was very reassured on return to DGRI that this would not happen here and strongly believe that we are more receptive and responsive, but could we do better?

Recently, one of our gynaecology patients who had been diagnosed with a terminal condition was moved between wards four times as her condition deteriorated. As long as her medical and nursing needs were being met, was it fair on her at this sad stage to have so many moves? Did we really think about what was best for her and her family and were we receptive to their needs?

In outpatients, how often do we ask patients to return for a “routine” appointment when they may not need to be seen in six months time, but have problems at a later date? Could we instead be able to respond to their needs and see them or even make telephone contact when really needed?

An elderly gentleman understandably complained because he spent a whole day travelling from the west of the region to Dumfries by patient transport, for a ten minute outpatient appointment to be given the result of a scan. In his own words, “he was not told anything that could not have been told by telephone”.

What routine investigations do we carry out that are of limited clinical benefit, often subjecting patients to yet further unnecessary investigations because of slight irrelevant abnormalities?

When questioning our practice, let’s also be prepared to be curious about that of others in hospitals to which we refer—recently a patient was referred to Glasgow for a gynaecological procedure. The procedure went well but the patient subsequently contacted me concerned that she had been asked to return to Glasgow for a follow up discussion. She wondered if a phone call would be possible in view of the huge inconvenience that this appointment would cause. I wrote to the consultant and asked if this would be possible. His rapid response was enlightening and reassuring: he had always brought patients back to a clinic as routine practice and never considered an alternative. He promised that from then on he would offer all such patients a telephone follow up instead.

Let’s use common sense and be prepared to challenge and bend the rules. Remember the ferry. While we do not have a “ferryman” waiting to respond at all times, we could consider the 4 “Rs”and be –

Responsive not Rigid,

Receptive not Routine.

Heather Currie is an Associate Specialist Gynaecologist and Clinical Director for Women and Sexual Health at NHS Dumfries & Galloway 

 

 

 

 

 

 

 

Decisions Decisions by David Macnair

Do you make decisions at work? I’ve asked this question a lot. The reply is usually the same. A hesitant nod of the head, perhaps. Or a lop-sided shrug with that expression that says “Dunno. Do I?” Despite making decisions every minute of every day, we most often don’t notice we are doing it. Which means we can make it better. We can ask, “Do you make good decisions?”

In fact, we human beings are decision making machines. We might make life or death decisions about patient care. But it is mostly humdrum day to day decisions. When am I going to get up for work? Which buzzer am I going to answer first? Shall I go for a pee before I do the next task? Should I push or pull that door?

First let us look at how we make decisions. These four categories cover most of the ways we make decisions in a clinical setting. They are:

  • Option appraisal
  • Rule based
  • Novel solution
  • Recognition primed

Let’s take a look at each of these in some more detail.

1: an example of a poor decision

1: an example of a poor decision

Option Appraisal

Do you recognise this heroic looking guy?

2: The Thinker

2: The Thinker

Option appraisal is the classical approach to decision making. One sits hunched with chin in hand and thinks of all of the possible options for a given situation. Each of these options is weighed up individually, looking to see the pros and cons. When finally a single best option is clear, a decision is taken. The major benefit of this approach is that it is the most likely to produce a good decision for the given situation. It is also easier to justify your decision later. Unfortunately, there are drawbacks. It requires mental effort and time. It requires a systematic approach. If you don’t know all the possible options, you could miss the right one! It requires some background knowledge. A medical example of option appraisal is writing a differential diagnosis. This is a list of possible illnesses (ie options) that a patient with particular symptoms might have. Writing a differential diagnosis forces you to consider diagnoses other than just the one you wrote first.

But is this how we usually make decisions? No! Of course not. If every decision we made required this process, we would become paralysed; unable to get anything done for thinking about it.

Rule based

3: Guidelines say we have to have 5 nurses on the ward. This is Sandra, also known as Claire, Fiona, Jade and Emma.

3: Guidelines say we have to have 5 nurses on the ward. This is Sandra, also known as Claire, Fiona, Jade and Emma.

This one is easy. Think of a guideline, any guideline. This can be thought of as a “rule” on which to base your decision making. A good example is basic life support. You know the drill (or you should- it’s mandatory!) There are benefits to having a rule. It’s fast. It standardises the decisions. If everyone knows the same guideline, then you can work together as a team. You don’t need to sit down and think- someone else has done the thinking for you.

There are buts. You know there is a guideline for cardiac arrest. What about the one for anaphylaxis? Or escalation of the deteriorating patient? Or the guideline for pre-eclampsia, or diabetes, or needle stick injuries, etcetera etcetera… The trouble is, you need to know there is a rule to follow it. You also need to be able to find that rule. Have you tried looking for a guideline on hippo? It’s not always easy.

Other drawbacks? It doesn’t allow you to think “out of the box”. Guidelines can sometimes be too rigid. Some guidelines are complex, and so easily misunderstood. In these cases, it might be most appropriate to have a copy of the rule to hand as you are carrying out the task. Also you can apply the wrong rule if you have picked up the cues wrong. It wouldn’t be the first time that a patient had been “defibrillated” because an ECG lead was hanging off…

Novel Solutions

While we are on the topic of “thinking out of the box”, we can take a quick look at this one. Novel solutions are things we think up on the fly when there isn’t a solution readily available. An example would be using a tongue depressor to splint a baby’s arm. These solutions are occasionally a necessity, but most likely to result in unintended outcomes.

4: The BBC substitutes sarcasm with inverted commas as the lowest form of wit

4: The BBC substitutes sarcasm with inverted commas as the lowest form of wit

Recognition Primed

Which brings us last, but not least, on to recognition primed decision making. It’s that pattern recognition thing. You walk in to a room and immediately just know what’s wrong. This way of thinking was described first when firefighters were being observed. When asked afterwards how they came to a decision, they would say only one option would come to mind, not a whole list like in classical option appraisal. They would then run with that idea, assessing at intervals whether the decision was having the intended effect.

This is how most of us do it. We make a decision from one single best fit option. The major benefit is that it is fast, sometimes supernaturally so. It doesn’t require much mental effort, and so is resistant to stressful situations. However, it is more likely to be wrong than a good sit down and think. In other words, some of your most experienced team members are more likely to be wrong because their pattern recognition has short circuited their decision making process. Be aware of this.

Thinking biases

There are other factors that can affect how we make decisions. Our decision making may be entirely rational, but there are biases that creep in to trick us. Here are some examples:

  • Confirmation bias. Take a diagnosis of bleeding for example. We tend to look for the symptoms and signs that confirm our diagnosis. We see the increased heart rate, the decreased blood pressure but ignore the wheezy chest that tells us the diagnosis not bleeding. This is a common failing when humans make decisions. Remedy? Take the symptoms that don’t fit seriously, and do not dismiss them.
  • Premature closure. In a similar vein, if we make a diagnosis, we stop looking for another diagnosis. Again this is common, and can often lead to missed problems. Remedy? First, use forcing functions, like writing a list of possibilities rather than just one option. Second, continually review your decisions especially in the light of changes.
  • Attribution bias. If something looks like a duck and quacks like a duck, we assume it’s a duck. So if someone looks and acts drunk, we assume he is drunk. Even if his symptoms are caused by a subdural haematoma. Remedy? Look for the facts to either corroborate or contradict your duck theory.
  • Base rate neglect. If something looks like a duck and quacks like a duck, don’t assume it’s a Christmas Island Frigatebird. Oddly, sometimes we do ignore the most common things and decide to pick the least likely option. Remedy? Assume it’s a duck. No wait…

5: Not a duck

5: Not a duck

H.A.L.T .

Our decision making may not be rational. We are human beings and there is most often more than one set of values at play. Decisions are often made when we are Hungry, Angry, Late or Tired. Or indeed is there some other conflict? Do you dislike the person you are making a decision for? Do you disagree with a senior colleague? This happens all the time. A couple of months ago I saw a patient in the emergency room with a head injury. The long and short was that his conscious level was decreased and he needed transferred to Edinburgh. The options were I could take him, or he could go with a nurse transfer. But I’d already been working for 12 hours by this point; the transfer to Edinburgh always takes 5 hours, and it was arguable that he was well enough to go with a nurse rather than an anaesthetist. Ish.

So the decision was made to transfer with a nurse (sorry Sarah). But I second guessed myself and phoned a friend. After discussion, he said “Well, if it was me, I’d go…” So I sloped back to the emergency department to find the patient already out the door! Further decisions were punctuated by interesting vernacular; suffice to say, I ended up in the back of an ambulance after some less than elegant decision making.

What can we learn?

On reflection, there are several things we could learn from this. We need to be aware when we are making decisions. This allows us to think how we are making decisions- is it recognition primed? Is it option appraisal? We can think what aids there are to help us such as rules or guides. We must realise what barriers are in the way of our decision making. Things like hunger, anger, lateness or tiredness can all be dealt with to improve our decision making.

Any last tips? Often it helps to stand back and take time to weigh the options. A colleague can be a valuable resource. If a decision is not clear, talk to someone about it. Possibly most helpful of all, it is important to reflect after the fact. What decision did I make? Did it have the desired effect? Could I improve on it next time?

Do you make good decisions?

David Macnair is a Consultant Anaesthetist at NHS Dumfries and Galloway

 

 

Lies, Damned Lies and Statistics…? by Penny McWilliams

The use of general anaesthetic for extraction of children’s teeth has reduced very considerably in Scotland in the past 20 years – quite right too, I’m sure most people would agree.

The Scottish government has arguably led the world in funding the Childsmile programme, which is intended to tackle the fundamental causes of poor oral health in children as early as possible, by providing multiple educational and preventative interventions in community and school settings.

Penny  3

Like most large scale health programmes and initiatives these days, it is accompanied by HEAT targets, one of which is for a reduction in the number of elective hospital admissions for tooth extractions for children aged under 3 years.

All very sensible and intuitive, and given the scale of the funding associated with Childsmile, it is hardly surprising that the impact on oral health should be monitored over time to see if the various initiatives have been effective. It would be fair to say that dental public health experts worldwide are interested in the long term success or otherwise of Scotland’s Childsmile project, to see if they should commissioning or implementing something similar. Changing people’s behaviours as opposed to increasing their levels of knowledge is notoriously difficult; looking back on issues such as smoking and drink-driving, we all know that changes have gradually occurred, but they have taken decades of health education and health promotion effort to bring about.

Penny 4The much improved access to dental care across D&G region since the mid-noughties, combined with the Childsmile activities by dental primary care and health improvement teams have been very successful in identifying those families most at risk of poor oral health. And we are much more successful than previously at providing appropriate dental treatment for young children with active tooth decay.

So paradoxically, the average age of many children’s first contact with a dentist has almost certainly come down, as many families now register with a dental practice for care. And the numbers of children aged 3-5 years being admitted to hospital for tooth extractions under general anaesthetic has certainly come down since 2003 rather than gone up, as the graph shows.

Chart 1 – DGRI Hospital admissions for tooth extractions in children aged 0-5 years old in 2004, 2009, 2013, and 2014 

Penny 1

But as you can see, the actual numbers of children under three admitted for tooth extraction are very low – only a couple a year on average. And some of these need an extraction because of trauma i.e. an accidental fall has damaged their front teeth, rather than tooth decay. And the average numbers admitted per annum have not really come down since 2009.

Very young children with painful tooth decay often now have much earlier contact with healthcare staff who successfully identify that they have dental treatment needs.

And those children for whom a tooth extraction is genuinely required, which can usually only be achieved by admission to hospital and use of a general anaesthetic, are arguably now more likely to get referred promptly.

If the whole point of HEAT targets from a government perspective is that ‘what gets measured is what gets done….‘ , where does that leave us when it comes to trying to achieve this particular target?

One way to achieve the HEAT target would be to leave the waiting times for admission long – children might be under three years old at the time of the decision to extract the tooth, but even with 18 week waiting time guarantees, most of them will be over three years old by the date of admission. Should we postpone provision of treatment in hospital for young children needing tooth extractions, because it would help us achieve the HEAT target? I don’t think anyone would advocate that, but could failure to achieve the reductions in numbers of hospital admissions be used to imply that oral health is not improving in Dumfries & Galloway region? Or NHS Dumfries & Galloway is not implementing the Childsmile programme properly?

We have already created local care pathways to ensure that the alternatives to extractions of deciduous teeth are available for young children, including active dental prevention strategies, and provision of more specialised paediatric dental treatment services. And because the risk associated with the use of general anaesthetic is very much higher than for routine dental treatment, dental general anaesthetic services are delivered in accordance with all of the currently available clinical guidelines, in as safe an environment as we can achieve.

I think it was Winston Churchill who talked about ‘lies, damned lies and statistics…’ and looking at the available figures general anaesthetics for dental extractions in children and Dumfries & Galloway over a period of years is pretty complicated. You can make an analysis of the statistics apparently illustrate almost anything you like.

Chart 2 below shows child admissions for general anaesthetic for dental extractions across Dumfries & Galloway region by quarter for 2013-14, arranged by age group. 

Penny 2

I could certainly argue for hours about what the figures and any mapping of overall trend does or does not tell us, based on this.

I’m sure that the original intent of the HEAT target was to see if oral health in very young children improves over time, particularly as it is well-known that children with complex physical, medical and social needs are at much higher risk of developing tooth decay. One can also assume it was intended to ensure that health authorities commissioned adequate local primary care dental services for families with young children.

But HEAT targets are very high-profile reporting measures, and failure to achieve them can very easily be misinterpreted, even by people who are entirely sincere and well-intentioned. Whatever the reasoning behind it, this one could become an unfortunate example of the misuse or misinterpretation of statistics.

Penny McWilliams is Director of Primary Care Dental Services for NHS Dumfires and Galloway

“What’s meant for us won’t go by us” by Gregor Purdie

After 30 years in General Practice, I’m now retiring and will be spending more time on my area of special interest of chronic fatigue.

This blog tells the tale behind how this interest developed and covers a number of factors that shape the pattern of our lives. Why do we do what we do? Who has encouraged and supported us to get there? What has been the spur to follow things through?

I can say exactly when my interest in chronic fatigue was aroused and how it impinged on my clinical practice.

Gregor 2When I was a resident – as we were called in those days – in 1979, I was working for Dr RW Strachan,(see left) Consultant Physician in the Infirmary. A patient was admitted with an illness where fatigue was a major symptom. Dr Strachan considered that this could be “Royal Free Disease”. This was named after the London hospital where much research had been undertaken into the illness which would become known as ME – myalgic encephalitis. Dr Strachan encouraged me to investigate thoroughly the patient and write up a report to send to the Royal Free.

The lessons learned from this exercise stayed with me and I began to note symptom patterns consistent with what is now called ME-Chronic Fatigue Syndrome in patients I saw in general practice.

One thing led to another. I was invited to meet with the local support group. One of my patients met with Thea Stein, our then Director of Planning, and I was asked to be clinical lead for ME-CFS.

This has taken me down a very interesting road over the years and has opened many doors. To mix my metaphors, it has not always been plain sailing. ME-CFS is an ill understood condition. There has been great debate and difference of opinion. It is a multi-factorial condition that can affect many systems in the body. It is characterised by fatigue and particularly post exertional fatigue. It is also characterised by joint and muscle pains, sleep disturbance and cognitive problems often termed “cognitive fogging” where people report that their ability to think things through can be lost through fatigue. There are bowel symptoms akin to irritable bowel syndrome.

We will all have experienced the fatigue after a viral illness and the time taken to recover fully from it. In some people that recovery does not seem to take place. Post viral fatigue is the commonest cause but there are other triggers which will need to be better identified.

Having seen patients in my practice who were fit and well and suddenly see a change in their functioning level after the index viral illness, I do believe that there is, as yet an unknown mechanism that triggers this condition. This can make a profound difference to people’s lives.

At one end of the spectrum there are the me-sceptics who do not believe that there is a physical element to the illness. There are patient groups who are certain that their illness is purely physical with no emotional or psychological element. Once when I spoke as a GP that I aimed to practice medicine holistically, I was told that that meant that I did not believe that ME was a physical illness and the holistic care was a way of doctors saying that it was a psychological illness.

In general, though, this road has been positive and very interesting and allowed me to become involved in research and development at a level unimaginable to me when I entered general practice.

Gregor 1

What has been achieved? There is now much more awareness of the condition. I find that when I speak to friends and colleagues, often there is a keenness to speak about someone they know with the condition. I’ve had the privilege through Alex Fergusson MSP, to bring this condition to the attention of the Scottish Parliament. I have developed links with both local support groups. I have a good working relationship with ME Research UK. This is a Perth based charity which supports biomedical research into this condition. I work with both the ME Association and Action for ME. These are two national charities which provide patient support and lobbying. They also provide a great deal of support to clinicians.

Gregor 3The biggest piece of work to date has been the Scottish Good Practice Statement on ME-CFS. Why a good practice statement? There is not the evidence to satisfy the requirement of a SIGN Guideline. There was a need to produce a document for clinicians in Scotland. We felt that the document, as well as giving guidance, had to reflect controversies over forms of treatment such as graded exercise and CBT.

It has been exciting to work with Action for ME in the development of educational packages. I’ve been introduced to the world of webinars. Now I know what it is like to read the news on the telly!

Locally, it has been great to work with clinical colleagues especially in physiotherapy looking at what we can provide in Dumfries and Galloway Professor Isles has also taken a keen interest in this area.

Back to the title! Like many, I’ve been blessed during my career by consultants and GPs who took an interest in the young pup. Dr Strachan’s encouragement has taken me down this clinical pathway which has shaped my career.

It behoves us similarly to enthuse and encourage to-day’s youngsters in the same spirit. It could become a greater legacy than could originally have been predicted.

 Gregor Purdie is a General Practitioner for NHS Dumfries and Galloway

 

Guidelines in Medicine by Dr Angus Cameron

I qualified as a doctor almost 35 years ago. Looking back it seemed to be a period of relative innocence. Time and blurred memory makes the reality of medical care then fade, but I am sure that we didn’t use the word guideline much then.  There were some clinical “rules” of course, but the vast number of guidelines didn’t exist then. There was much more variation in the care that was delivered, with the doctors personal preferences going relatively unchallenged.

Since then of course, the technical care of patients has become much more standardised, and this has undoubtedly led to improvements in the outcomes for patients. The concept of clinical audit developed in the 1980s, and we started measuring how many of our patients got the standard of care that had been outlined by the relevant guidelines. Where audit results were poor we started improving to ensure that almost all patients who could benefit were treated according to the most up to date guideline.

There followed a period where guidelines began to multiply, and many of the most experienced doctors nurses and pharmacists found themselves sifting through clinical evidence from trials and spending long hours developing guidelines. They were published by a vast number of groups and soon there were also local guidelines in each Health Board.

SIGN (The Scottish Intercollegiate Guideline Network) was born in an attempt to give more authoritative and unbiased guidance to clinicians.  This was a world leader (and probably still is), publishing guidelines that tended to be much clearer than others, and also included an assessment of how strong the evidence supporting each bit of the guideline was, allowing the clinician to have confidence in interpreting the guidance that was presented. SIGN was, I recall, ground-breaking in that patient groups were invited to join the guideline development panels.

SIGN guidelines are published in glossy booklets that were sent out to all GPs. They had a wonderful smell of fresh ink, and although the format was largely standardised each had a different coloured cover so that you could rapidly find the one that you wanted in the pile of papers and magazines that lay in the corner of your room.  When they arrived in the post I would glance through them: Some were not really relevant to general practice (I was a GP in the Scottish Borders then), but they were to be revered, and not to be discarded. On busy days I saved them for later reading. A pile of them grew steadily in the corner of my consulting room, sadly neglected, and tending to stick to one another as the once sweet smelling ink dried and stuck them together. When I left general practice I had over 100 of them. I couldn’t throw them out, but left them in a neat chronologically ordered row for my successor who would no doubt wonder if I had lived up to the standards espoused by the guidelines.

Guidelines began to interest lawyers. Around about 2000, failure to follow a SIGN guideline was discussed by a Sherriff in Glasgow who was hearing a fatal accident inquiry into the death of a patient from epilepsy. The SIGN guideline was clear in saying that General Practices should have distinct clinics for patients with epilepsy to assist a practice in providing structured, proactive care. The sheriff was extremely critical of the practice in not having such a clinic. He noted that they had failed to follow authoritative opinion in their provision of care, and were therefore guilty of a significant failure. Inevitably lawyers and doctors began to view guidelines in a different light. Lawyers would read and understand guidelines when dealing with medical negligence cases, and doctors would worry about ensuring that they were following them, and keeping up to date with them.

Guidelines have been incorporated into the Quality and Outcomes Framework of the GP contract since 2004, and the payment to GPs is significantly determined by their compliance with guidelines in a number of diseases- giving another incentive for GPs to follow guidelines, even if they hadn’t already felt compelled to do so by potential litigation.

But I sense that there is growing concern about some aspects of guidelines, and I share those concerns.  This is difficult to say as a professional (still less a Medical Director) “How can you possibly want to ignore guidelines and bring back substandard care” others would say.  Des Spence, a regular (and somewhat irreverent) contributor to the back pages of the BMJ talks of the “tyranny of guidelines” and the difficulties of railing against what now sound like compulsory edicts rather than helpful guidance. And sadly there is increasing evidence that there are commercial interests hovering around the production of guidelines: Guidelines can help sell vast volumes of medications.

Let me try to explain some of the concerns I have about guidelines.

Firstly they are so often misquoted. If you go back to the original guideline they often say something along the lines of  “Drug X should be considered for ….”.   The cool and sophisticated pharmaceutical company representative who comes to see you will, slightly challengingly, suggest to you that the guideline says “Drug X should always be used”, and, not actually having read the guideline in detail yourself you feel obliged to consider changing your clinical practice in the face of what you believe to be incontrovertible evidence.  And of course the pharmaceutical rep (if you are unwise enough to see them) will have selected a particular guideline – there may be others that disagree.

Secondly, they are often unarguably correct when first developed, but over time they become extrapolated. A guideline may, for example, say, quite correctly, that patients with moderate to severe asthma should be given a steroid inhaler.  This is absolutely correct. But gradually this message is reshaped in practice, and the principle is applied to patients with less and less troublesome asthma, until the patient with only occasional mild wheeze is given a steroid inhaler with “doctor’s orders” to take them on a regular twice daily basis.  Taking a medication to prevent symptoms is of course more profitable for a drug company than only taking medicines when you are ill.

Thirdly, guidelines are often developed regarding patients who are relatively young, and who only have one particular illness. But in the real world this doesn’t happen often. As more of the population survives into older age, older patients (who metabolise drugs differently and who are more susceptible to side effects) have multiple illnesses, and so following the guidelines for each of the illnesses that they have (or are at risk of developing) results in patients facing a mountain of medication each day, often with resulting problems of confusion, falls, constipation, tiredness and the rest. So of course there are new guidelines developed on how to deal with polypharmacy – the use of large numbers of medication.

Lastly, some guidelines are found to be wrong as knowledge develops.  A group of researchers some years ago reviewed all articles published in the New England Journal of Medicine in the course of 1 year, and noted that 17  (I think it was 17, I haven’t got the reference to hand) of the articles showed evidence that a basic guideline needed to be either withdrawn or significantly corrected.

But let me end with my personal evidence that guideline development may be subject to commercial pressures, and that lobby groups may push to influence clinical practice.

A letter arrived two years ago inviting me to dinner in the Scottish Parliament. The letter suggested that as an opinion leader in medicine I would be very welcome to attend a dinner in Holyrood with MSPs and doctors, hosted by the Atrial Fibrillation Association. I’m easily flattered and accepted with eager anticipation. I noted from the impressive website that the association had been recently founded to “increase awareness of atrial fibrillation” (a condition where an irregular heart beat occurs which may lead on to stroke in some patients). Cynically I wondered if the association and the website had had funding from a drug company that was soon to launch a new form of anticoagulant that could be used instead of warfarin for patients with atrial fibrillation.  (Warfarin “thins” the blood and prevents stroke in atrial fibrillation). The new medicine costs almost 36 times more than warfarin and could potentially be used on thousands of patients who are currently on warfarin. While the new drug does not need regular blood tests to monitor its impact, it has only marginal improved effect in reducing stroke – and of course is not without problems itself.

The member’s dining room in Holyrood is impressive and I felt somewhat overawed as I sat at a table with MSPs some of whom I recognised from the papers. The meal was modest but accompanied by excellent wine. Half way through the meal an extraordinarily beautiful lady stood up at one of the tables and began to talk about atrial fibrillation, noting that it affects up to “one in four” of the population (in fact only about 2-3000 in Dumfries & Galloway), was associated with a “very high” risk of stroke (not an accurate representation)and was treated by a drug that was extraordinarily old-fashioned, used as a rat poison and extremely dangerous. She described in beguiling tones how the association needed support from opinion leaders such as the dinner guests to ensure that new advances in treatment could be made available to the population, along with a concerted screening problem to find patients with atrial fibrillation who had no symptoms. Her words implied an extraordinary number of patients of all ages developed strokes, and seductively implied to those present that the cost of a new medicine would be more than offset by the reduction in the number of strokes.  Her talk was very slick and convincing, but at considerable variance with conventional medical evidence. Several of the MSPs asked questions, and in the answers, the presenter urged them to push their local health boards to make the new drug readily available.  “This is such an important issue that it can’t be left up to clinicians to decide” seemed to be the message – “politicians need to unite to rid Scotland of its poor stroke record.”

I’ll never get invited back to Holyrood.  As an “opinion leader” I stood up and said that I felt anxious that this discussion was not about raising awareness of atrial fibrillation, but about raising an appetite for a drug that would not by itself reduce the rate of stroke in Scotland significantly, and would potentially increase our drug spend in Dumfries & Galloway by £3 million pounds. I felt I was ignored and was made to feel naive: The evening ended with several of the “opinion leaders” having their photo taken with the amazingly beautiful lady, and pledging to hold their local Health Boards to account and force them to take up the new medicine.

I’m old and cynical, and I should recognise that there are good people who work with the association, and there are excellent guidelines that have shaped medicine to become safer and more effective.  But sympathise with me in my belief that guidelines need to used with caution, with appreciation that there may be vested interests in their development, and that all too often they are becoming rules rather than guidance. In summary, “they should be considered” rather than followed slavishly – this is what professionalism is all about as we combine medical knowledge with sympathetic understanding of patient’s problems and preferences and provide holistic care.

I think as a doctor I shall keep out of Holyrood. And perhaps politicians should keep out of medicine.

Angus Cameron is Medical Director for NHS Dumfries and Galloway

Next week’s blog will be by Dr David Hill (@davidmhill55) Consultant Radiologist NHS Dumfries and Galloway