- Freedom from only doing ordained tasks is essential for mental health.
- Beware accepting a protocol without knowing if it will affect your sympathy and time to communicate.
Sympathy is a delicate flower which has often withered before the end of morning surgery. If a protocol says that you must do 10 things to Mrs James who happens to have diabetes, both of you may be irritated by item 5: the doctor is running out of time, and the patient is running out of goodwill. She is really worrying about her husband's dementia, having long-since stopped worrying about her own illnesses. She does not mind being assailed by lights, forks, stix, and lancets, if this is the price for a portion of her doctor's sympathy. But if she finds that this sympathy has withered, who knows what her feelings may be, and how she will view her doctor?
Guidelines are seen as friendly, if flexible and allow for the frailties of clinical science as it meets bedside reality; they can also be interactive, if instituted in a computerized record during the consultation. Protocols, particularly if they have been handed down from some supposedly higher authority, have a reputation for being strict, sinister, and stultifying instruments for thought-control. How well do these stereotypes stand up in practice? It is known that doctors working in highly regulated environments with strict protocols perform suboptimally.49 It is also worth noting that very few laws are flexible: those which are, are dangerous because they invite abuse. (All men are equal, but ). But what laws can do is to state when they don't apply. This doesn't necessarily make them mere guidelines. You could say, that patients have a right to be asked if they want to participate in a protocol, and if they do, that it should be done properly. But what if it is the child's birthday today, and he really does not want to have his finger pricked for a glucose test, but he is most willing to go along with all other aspects of a protocol? If you are flexible, the price may be ketoacidosis after the party. Herein lies the paradox of protocols. They are designed to remove the many indefensible inconsistencies found in clinical medicine, yet the protocols depend on the individual doctor's own flair and instinctive judgment to be applied in the best way.
Perhaps the best approach is to welcome the good protocols, and develop some sort of meta-protocol which should be answered whenever (or almost whenever) such protocols are not adhered to. Why did you not adhere to the protocol? Please tick the appropriate box.
- My own convenience.
- The patient's stated wish.
- The patient's stated wish after being given full information.
- The protocol is contraindicated in this case because my instinctive flair and judgement tells me so.
Can we square guidelines & targets with patient-centred care?
Answer: No; discussing this issue with purveyors of guidelines is a good way reveal the hidden agendas described above. Point out that leading authoritities1 are now saying patients must decide their own target BP, HbA1c, etc.
In conclusion, each protocol should come with a comment on the likely effect on the doctor's sympathy; how often, on average, one would expect the protocol not to be adhered to; and what resources and time will be needed, and how this will be funded.
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