Dr Peter Moore: Protocols must take into account the art of medicine as well as the science
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Dr Peter Moore, former Torbay GP, writes for the Torbay Weekly
When I was a student I sat in on a single-handed GP in the east end of London. His wife acted as receptionist, secretary and everything else.
There was no practice nurse and hardly any equipment. But he had been a GP there for many years and knew his patients.
One day, a man came in with backache. There was nothing that I had read in the books or in lectures to suggest any other problem but the GP had a gut feeling this was not straightforward.
He carried out a thorough examination including a rectal exam, took blood and referred him to hospital. The following week he told me that the hospital had confirmed his suspicions: he did have cancer of the prostate.
As I became more experienced I began to understand the 'magic' of this brilliant GP. I developed my own gut feelings. Having known a patient over the years and watching the 'non-verbal' cues occasionally I would get a feeling 'something's not right'.
The problem was that, in the modern NHS, there are guidelines and protocols. There are boxes to tick. Referring a patient to a specialist because I have a gut feeling that 'something's not right' is not acceptable.
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Like most of my colleagues, I could get round the problem by knowing what was needed in the referral letter. I could emphasise the symptoms and signs which would tick the right boxes. But is this good practice?
At last there is now some research which gives some scientific credence to gut feelings.
In a study published in the British Journal of General Practice, researchers looked at 12 articles and four online pieces of research.
They found that gut feelings of experienced GPs are more effective at diagnosing cancer than the official guidelines. The accuracy of the gut feelings increased as the GPs became more experienced and knew the patient better.
Although we all learn medicine by lists of signs, symptoms, an examination and investigations, over the years doctors learn short cuts.
It was once suggested that it can be like recognising a bus. When I see a bus I could refer to a list; has it got passengers, has it got a notice on the front or even is it a double decker? But I don't. I recognise a bus because I have seen a bus before.
Experienced doctors recognise that someone is just 'not right' because they have seen ill patients before even if they cannot be sure of the diagnosis.
We are not the only profession who rely on gut feelings.
Some years ago an experienced police officer saw a 'drunk' in the street. He had seen hundreds of drunks before but he had a gut feeling about this man. He rang for an ambulance. The crew did not agree.
After an examination and referral to their protocol they insisted that he was 'just drunk'. He was taken into the police station where he died of a head injury. The experienced, older police officer's gut feelings were right.
A good teacher can tell whether a class has understood, a good nurse will know that a patient has deteriorated and a good social worker will be concerned about a family without necessarily having any concrete evidence.
Gut feelings can be wrong but that does not mean that they should be ignored.
The question that this research opens up is will a doctor get the same gut feeling over the phone or in a video consultation? Will the gut feelings be as effective if patients don't have 'their own' GP? If patients are triaged by people not medically qualified using a protocol will these gut feelings get missed?
Further research might uncover what triggers an experienced doctor's 'gut feelings' but, until we really understand the science behind gut feelings, the rigid protocols must take into account the art of medicine as well as the science.