Ahmed Rashid on “Goldilocks Medicine”: the quest for “just right”

ahmed_rashidWeek after week, NHS general practitioners receive messages about changes they should consider making to their clinical practice. These messages come from national and local guidelines, research papers, blogs, social media, and articles in the medical and lay press. It can often feel like these messages are pulling doctors in all sorts of different directions. In particular, two major narratives seem to conflict. One of them, emerging perhaps most typically from guideline producers, urges general practitioners to take a more proactive and aggressive approach to managing risk factors and diseases. The other, exemplified by The BMJ‘s Too Much Medicine campaign, urges a more cautious approach that acknowledges the harms of overdiagnosis and iatrogenic harm. 

So, which of these messages should trainee general practitioners be listening to? Is the profession too soft, too hard, or indeed, just right? This question was the central theme of the “Goldilocks Medicine” study day for general practice specialty training doctors that took place in Cambridge in January 2016.

The first session of the day was on screening. After briefly revisiting the basic principles of screening, the main focus of Professor Simon Griffin’s talk was on the ethical challenges and potential for harm in current national screening programmes. These harms, the audience were reminded, extend beyond the physical and psychological harms of the tests and treatments to the distraction from wider collective determinants of health. He then went on to talk about screening for diabetes and particularly, the ADDITION-Cambridge study that he led.

In a characteristically engaging and amusing talk, David Spiegelhalter, the statistician and Winton Professor of the Public Understanding of Risk at the University of Cambridge reminded the audience that good communication of risk contributes to informed choice and also breeds “immunity to misleading anecdote,” giving some truly outrageous examples of deceptive media reporting of health stories. After sharing a number of examples of risk communication tools, he finished with a critical analysis of the recent government alcohol guidance.

The main interest in the blood pressure session was the recent SPRINT trial. Although this trial has confirmed that more intensive blood pressure targets can improve outcomes in some scenarios, it remains unclear what the implications will be for future practice in UK primary care. There were also important reminders that definitions of “hypertension” are arbitrary and the use of ambulatory and home blood pressure monitoring have been important methods to help prevent overdiagnosis.

Participants then broke off into two workshops. One focussed on patients’ experiences of taking medications and included two very realistic (and challenging) cases involving medication reviews of patients facing polypharmacy, leading to much lively debate. It was generally accepted that there should be more focus on regular medication reviews and in particular, they should be done face-to-face whenever possible. The other workshop covered the crucial topic of shared decision making. An important message that emerged was the huge number of useful resources that doctors might try to use in consultations including decision tools and option grids.

The afternoon session focussed on quality and professionalism, with Professor Martin Roland telling the story of how QOF came into existence and importantly, how they have lost popularity due to the fact they poorly align with professional values and are too focused on single conditions. The conversation then turned to the recent national review of the primary care workforce and how primary care teams might operate in the future. The expansion of the primary care team may allow general practitioners to spend more time with complex patients with multiple conditions and the presence of pharmacists within practices may allow more time to be devoted to regular medication reviews.

The final session of the day was run by BMJ blogger and evidence-based medicine guru, Richard Lehman. He described his ten commandments for patient-centred care, taking care to explain how they might fit into the choppy waters of the modern NHS. There was much thought-provoking debate about the fine balance between benefit and harm in clinical practice and how a focus on patient outcomes can in many ways transform the care that doctors provide.

Guidelines and protocols can be comforting for junior clinicians and it can often require much bravery to step outside them. As population demographics change and multimorbidity rises, so will the number of challenging consultations and clinical scenarios. One study day is clearly insufficient to cover this enormous area but that a large group of future general practitioners discussed and debated it with so much passion and reflection is promising. It may well be early days in the search for “just right” but at least we’ve started looking.

Ahmed Rashid is an academic clinical fellow at the University of Cambridge. You can follow him on Twitter @Dr_A_Rashid

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I hereby declare the following interests: None.