Practicing medicine

I qualified as a doctor in the year 2000. It took me six years of training to qualify as a GP. I took a slightly convoluted route via surgical training and Australia and started seeing patients as a family doctor in 2006. It’s very different to being in hospital. Firstly, you have 10-12 minutes per patient (if you are lucky) and one patient booked after another with perhaps a couple of gaps (if you are lucky) for anything up to 3 hours. This is a bit crazy, but like living in a dysfunctional family, it feels normal after a while.

To qualify, I had to pass some exams. A large part of the material I needed to study involved learning clinical guidelines. These are the basis of Evidence Based Medicine (EBM). EBM is designed to standardise treatment for patients using the latest evidence from clinical trials. I found a certain cognitive safety in knowing the guidelines. In recent years, the culture in medicine has changed drastically and doctors are now expected to follow the guidelines to the letter or risk punitive consequences if something goes wrong.

Personally I have no issue with standardising care and providing a framework for doctors to base their clinical work on. The problem is that people are far more unpredictable than the rigidity of the guidelines. When doctors follow guidelines rigidly out of fear for the consequences of missing something, they can forget about the fellow human in front of them. Too often I have seen doctors tick all the “guideline” boxes perfectly but the patient fails to get better. They are then too frightened to do something different with the patient “in case something goes amiss”. Clinical judgement and creativity are sidelined for box-ticking and protocols.

If that wasn’t worrying enough, we find that some of these guidelines are curated by people with monetary links to the pharmaceutical industry and the best available evidence changes on a regular basis. Even patients find it confusing when a we have to change a drug that they had been taking because it’s now been found to be unacceptably harmful.

I suppose in some ways it is good that the guidelines are regularly updated. It’s not good to let the pool get too stagnant. One of the problems with EBM is that the guidelines are only as good as the quality of the clinical trials that underpin them and the bedfellows they court – namely the pharmaceutical industry.

I don’t have a problem with pharmaceuticals per se either. For the right patient, in the right context they can be lifesaving. Western medicine very much bases its approach on the infectious diseases’ “one cause, one effect” model. This works very well for something like a fractured bone for example. The cause is usually easy to see, and the solution is fairly straightforward. Similarly with acute tonsillitis. The cause (usually Group B Streptococcus), the solution – good old penicillin. Most of the people who come and see me in my office, do not have such clear-cut problems. They are complex. The symptoms are vague. They do not easily fit into a diagnostic category – no matter how hard we may try to stuff them into some DSM box.

Take “depression” for instance. Is that experience really as simple as a chemical being out of whack in the brain? Big Pharma would have us think so despite the fact that there is no concrete evidence for the “chemical imbalance” theory. It’s more complex.

To get to the route of depression (if that is even possible), one has to listen to the patient’s story. Their narrative, beliefs, fears worries and stressors. It’s helpful to look at the quality of their social connections, diet, exercise, what they do with their time etc etc. It’s contextual and it’s not going to be 100% fixed by taking an antidepressant in my experience. That’s not to say that these drugs are not lifesaving for the right person. But there’s more to it than that. Western medicine tends to learn heavily on treating symptoms rather than looking for root causes in these complex conditions. For me, the most enjoyable part of the job is helping people. Listening to their stories. Sharing a joke and marvelling at the wonder of the human body to share its wisdom with us.

Image by Myriam Zilles from Pixabay