{"id":31722,"date":"2014-06-05T15:50:51","date_gmt":"2014-06-05T14:50:51","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=31722"},"modified":"2014-07-28T16:32:59","modified_gmt":"2014-07-28T15:32:59","slug":"neal-maskrey-seeing-the-world-through-a-patients-eyes","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/06\/05\/neal-maskrey-seeing-the-world-through-a-patients-eyes\/","title":{"rendered":"Neal Maskrey: Seeing the world through a patient’s eyes"},"content":{"rendered":"

\"neil_maskrey\"<\/a>Captain Hawkeye Pierce of the 4077th MASH unit is one of the great fictional doctors<\/a>. Battered by the US army, and brutalised by death and disfigurement in a war far from home, he made mistakes, he was human, he cared. We laughed, cried, and loved him. Alan Alda and the rest of the cast of MASH<\/em> personified why the arts are important. For 30 minutes every week at the height of the Vietnam war, a worldwide audience reflected afresh on the futility of war. At its best, art forces us to see the world through others\u2019 eyes.<\/p>\n

From the rarefied atmosphere of the World Cardiology Congress in Melbourne, I read how poorly we sometimes put the best of evidence into practice. This time it’s asthma, and, while deaths from asthma in many age groups are in fact falling, I inwardly sigh and know we can do better because this happened a few months ago . . .<\/p>\n

A *patient, \u201cTeacher\u201d as I\u2019ll call her, had her asthma well controlled on Symbicort. Well controlled, but not reviewed for three years, so no discussion of stepping down. Hoarseness and a sore throat began to develop and persisted. GP consultation one: probably viral (reasonable). But it gets worse. GP consultation two: must be viral, stay off work for two weeks. \u201cCouldn’t it be something to do with the inhaled steroid?” asks Teacher helpfully. “No” says GP. GP consultation three: still hoarse, still off work, and the side effects from the codeine for the pain are worse than the pain. We’re now way over the \u201crefer for laryngoscopy for persistent hoarseness\u201d deadline in another guideline, but that doesn’t happen either. “I wonder if it could be your inhaled steroid” says the GP. He stops her Symbicort and starts fluticasone,\u00a0increasing\u00a0the steroid load on Teacher’s upper airway and larynx.<\/p>\n

The story ends happily. By good fortune, Teacher had to move house and re-registers with her old GP practice. She takes the NICE “I\u2019m persistently hoarse, refer me” guideline along and gets referred. She sees the asthma nurse and gets the steroid dose dramatically reduced with no loss of asthma control. She looks up vocal exercises on the internet and starts to turn the corner. The rapid indirect laryngoscopy is (joy of joy) normal. With a phased return to work, Teacher’s life returns to something that\u00a0resembles normal. After three months.<\/p>\n

There are many reasons why, despite our best efforts, things occasionally don\u2019t go as well as we would hope. It\u2019s definitely not down to lack of intelligence, commitment, or caring. I don\u2019t meet anyone in the NHS who isn\u2019t working their socks off. But as George Bernard Shaw wrote: \u201cSuccess does not consist of never making mistakes, but in never making the same one a second time.\u201d<\/p>\n

In “Goodbye, Farewell, Amen,” the final two hour MASH<\/em> episode watched by a record US TV audience, the uneasy truce holds and Hawkeye plans to return to his father’s practice and \u201cget the good people of Crab Apple Cove to say \u2018Aaaargh.\u2019” So how would our hero, now a family physician, handle evidence, guidelines, and implementation?<\/p>\n

I reckon he\u2019d have understood that the time with which he had to keep up to date was limited, and that his own cognitive capacity was also limited. He\u2019d have recognised the good sense in Slawson and Shaughnessy\u2019s work<\/a>, which recognises that first base is to be really up to date with the best available evidence for conditions that\u00a0present commonly.<\/p>\n

An hour a week on keeping up to date is realistic, such is the pace and volume of clinicians\u2019 workload. For a GP, 30 to 40 conditions<\/a> covers about two thirds of problems that\u00a0present. So an approach might be to \u201chot-synch\u201d our brains about once a year with short, trusted, public sector summaries of evidence\u2014looking particularly for instances where we think we do one thing, but the evidence says we should change our practice. I bet Hawkeye would also check some audit data on those common conditions to see if what he thought he was doing was what he was actually doing. The GMC thinks that\u2019s a good idea too<\/a>.<\/p>\n

Even without Hotlips Houlihan<\/a> and Radar O’Reilly<\/a> around, I reckon Hawkeye would be on the ball in Crab Apple Cove. It’s reasonable for doctors, all doctors, to be really good at treating the conditions they see commonly. It\u2019s not going to fix all of our mistakes by any means, but it\u2019s a logical, realistic plan, and it might sometimes prevent us feeling really bad about stuff that\u00a0has gone wrong.<\/p>\n

And thanks, Teacher. Patients’ experiences can work as well as the arts. You too made me see the world through another’s\u00a0eyes.<\/p>\n

*Permission was obtained from the patient “Teacher” in this blog.<\/p>\n

Neal Maskrey’s<\/strong>\u00a0early career was as a GP before spending seven years as a medical manager and part time GP. After 12 years as a director of the National Prescribing Centre and programme director at NICE, he is now honorary professor of evidence-informed decision making at Keele University, and consultant clinical adviser in the Medicines and Prescribing Centre, NICE.<\/em><\/p>\n

Competing interests: I declare that I have read and understood the BMJ Group policy on declaration of interests and I hereby declare the following interests: Employed part time by the National Institute for Health and Care Excellence.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Captain Hawkeye Pierce of the 4077th MASH unit is one of the great fictional doctors. Battered by the US army, and brutalised by death and disfigurement in a war far […]<\/p>\n

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