In article <0309201048560J.21897@osborne>, Adrian Midgley
<[log in to unmask]> writes
>on Saturday 20 September 2003 03:23, Rakesh Biswas wrote:
>
>> "Its a pity that a profession so devoted to care of individuals should
>> care so very little about individuality."
>
>As a GP I'm conscious that a managerial approach evident in our new
>contract is pressing us to deliver more standardised care.
>
>Clearly this is because the managers and politician, some of whom have
>learned some medicine or spoken to the great and good about it, believe
>that this is better than the current approach, and I'm not able to show
>they are wrong.
I think that a large part of the concern about a non-EBM approach does
not stem from a lack of understanding of the complexity (that art bit)
of medicine, but a concern that patients are begin treated differently,
not based upon differences between patients assessed carefully by
experienced clinicians, but because of the differences between the
patients' clinicians levels of knowledge. skills and, more worryingly,
their personal values. It is also because humans are actually not all
that good at doing the same thing in the same circumstances.
>
>Genomic research may let us predict the best drug (or other treatment) for
>someone, compared to others with the same health need, or the required
>frequency and type of monitoring of a standard treatment on a better basis
>than we do at the moment, but I would find it handy to be able to show
>that people vary, and show that it is possible to look at someone and
>choose the best first or second hypertension drug for instance.
>
>I am quite sure they do, and I can, but I can't _prove_ it.
>
>Or can I?
I suspect you could make a start to explore it. Is it possible to
construct a trial (probably cluster randomised) where some patients are
treated for a common condition, where patient variability is
acknowledged. Some could be treated "by the book" so to speak, others
by the experience of the clinician. It is increasingly possible to know
the extent to which the guidelines were adhered to. If the trial were
large enough the variability between clinicians would not be a factor.
Could use chronic (high BP, diabetes) or acute (AMI) problem. I
actually can't believe, though I haven't looked, that it hasn't been
tried. This is actually very pragmatic, and would help inform what we
should DO, in the interests of patients, even if it doesn't give chapter
and verse on the mechanisms involved.
Comments?
--
Dr Ian R Bowns FFPHM
Honorary Senior Research Fellow
Health Policy and Management
School of Health and Related Research (ScHARR)
University of Sheffield
Regent Court
30 Regent Street
Sheffield
S1 4DA
Tel; 0114 2220742
Fax; 0114 2220798
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