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Joe Collier: Coping with conflicts and uncertainty

26 Sep, 08 | by BMJ

Professor Joe CollierRecently I met a student who had been in a Problem Based Learning (PBL) group that I had ‘facilitated’ in 2006. During the PBL we will have spent around six hours together each week for a full trimester (so around 72 hours contact time in all) and I was interested to know if he could remember learning anything specific from his time in the group. Not surprisingly he could not recollect any specific facts but there was a much broader issue, that of tackling conflicting advice, which did come to mind. This was of a different order and both of us remembered the circumstances well. The student was a graduate entrant who prepared thoroughly, engaged willingly, and epitomised equanimity. Then, one morning, things had changed as he sat at the tutorial, glum, downcast and withdrawn. After a post-tutorial chat I leaned the reason. During the week’s ‘preparation’ he had come across advice in respected clinical guidelines that conflicted in serious respects. What was he to do; who was he to believe? Suddenly medicine had got a whole lot more complicated and he could see no obvious solution – could decision making as a doctor ever be possible?
His was an extreme, albeit legitimate, response to a problem – however, conflicting advice from experts, opinions leaders, guideline producers, government departments, teachers, internet sites, or local treatment policies etc, is commonplace and can be difficult for anyone. It is, after all, a root cause of postcode prescribing. I became particularly aware of this issue when, as editor of the Drug and Therapeutics Bulletin, I published advice on the use of the anti-flu drug zanamivir that conflicted with advice given by NICE. The conflict would obviously cause consternation amongst our readers and disbelief amongst officials, but nevertheless I had no reason to doubt the intellect or integrity of either ourselves or NICE.
My response to this dilemma remains as it was then 1) recognise that conflicting advice is common and usually legitimate; 2) conflicts may be explained because the interests/terms of reference of the information providers vary and so are at odds with your perspective and those of each other (this was probably the issue in the conflict between DTB and NICE); 3) when deciding on the advice to follow take into account the context in which you are operating (as a student it is probably safest to follow a teacher’s advice, in a local hospital the advice of the local guidelines is key etc; 4) if it is possible to gauge the skill/intellectual input of the provider go for the provider with the best record in these respects. In other words, back the stable and not the horse; 5) ultimately develop a hierarchy of trust for guidelines relating to your particular circumstances and stick with it.
Back to the minor issue of what we learn from particular teachers. In my view teachers are rarely remembered for imparting ‘specifics’, it is more the principles and sentiments that adhere. Forty five years on I can still remember my old professor chiding me for being obsessed with getting a diagnosis with the advice that it’s ‘better to be a living mystery than a dead cert’. Now that’s teaching.

Joe Collier is emeritus professor of medicines policy at St George’s, University of London.

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