In message <[log in to unmask]>, TreforR <[log in to unmask]> writes
>Minerva writes in the BMJ 1998 316:948 reporting Sir Douglas Black writing in
>J Roy Coll. Physicians of London (1998;32:23-6) who has some doubts about the
>infallibility of evidence based medicine. He (Sir Douglas) quotes a Robert
>Platt who wrote " The art of medicine remains the art of identifying the
>patients problem (which is something more than merely diagnosing his
>disease.)"
>
Of course that's true. Evidence-based medicine just makes the process
more explicit and (dare I say it) more effective.
>Rationing makes the situation worse. With a shortage of resources, who gets
>the evidence based medicine, or more realistically; which evidence based
>medicine should one choose on a cost limited budget. Statins for secondary or
>primary prevention, or hip replacements or anticoagulation for AF or what?
>
These are difficult decisions which we don't like having to make...
>I have a real fear that the Primary Care groups emerging in the UK will force
>clinicians on the ground into making such rationing decisions. I have resisted
>becoming involved with the rationing of care for 5 years. I have tried to
>apply the reasonable, up to date standards of care with the result that
>despite an 80% generic rate I have exceeded the suggested drug budget every
>year and my drug costs are growing.
>
...but cannot avoid. The danger is that Primary care Groups will develop
too much of a population based decision making approach and not pay
enough attention to the individual patient. The clinician on the ground
must still try to achieve the most effective outcome for each individual
patient (s)he sees - but will sometimes be limited by cost, and that's
life. One of the things we can do is cut down on unnecessary (effective
but not important) or ineffective interventions in order to free up
resources for important and effective interventions. For instance, much
radiology is unnecessary, many other diagnostic tests do not aid the
diagnostic process, SSRIs are not more effective than TCAs, and so on.
>I realise that there are no quick fixes, but why should my clinical decisions
>be influenced, not only by the best in evidence based medicine but also by the
>irrational, non evidence based, rationing of care by random events and
>personal prejudices. The patient in front of me deserves the best evidence
>based medicine, but if society cannot afford it, I am surely not the one to
>decide if they get it or not.
>
But you are the one best placed to get the most out of what resources
are available - and to resist wasting resources. Don't forget that in a
large proportion of patients presenting in primary care, the best
evidence-based "intervention" is to do nothing...and believe me, all you
secondary sector lurkers, it is often more difficult to do "nothing" in
primary care than to do something wasteful and useless!
Toby
--
Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel
0191-2811060 (home), 0191-2437000 (surgery)
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