Abstract
During my first shift as a foundation doctor in a large teaching hospital, I was sent to the emergency department to see a lady who had taken a Paracetamol overdose. Keen to impress the on-call medical registrar, I set about ordering the appropriate investigations according to the latest guidelines. As it turned out, the on-call registrar that day was a senior hepatology registrar. ‘Don’t you know Paracetamol overdose causes liver failure?’ he asked me, patronisingly. He then set about reeling off a long list of tests that I would need to request for a ‘full liver screen’ and I dutifully obliged, ignoring the guidelines and trust protocol that had no mention of these uncommon (and expensive) investigations.
As I reflect on this experience years later, I wish I could go back in time and challenge him on this. His reasoning seemed to be that if the patient turned out to have impaired liver function, it would be important to ensure that this wasn’t caused by a pre-existing condition or infection. While that may seem logical, it ignores the fact that the large majority of individuals who take Paracetamol overdoses have absolutely no liver impairment at any stage. Reserving these expensive tests only for those individuals who have been identified as having impaired liver function would therefore save time and money and prevent patients from having to endure potentially unnecessary investigations. These factors were surely considered by the guideline producers, who had not included such a comprehensive routine screen in their recommendations.
It’s clear to me now that the reason for making me request those tests wasn’t about patient safety, effectiveness or experience at all. Rather, it was about professional ego. It was an opportunity for him to flex his intellectual muscles and demean a junior colleague. While this is, of course, highly problematic in an educational and pastoral sense, it is also a dangerously careless use of public resources. Professional hierarchies and ‘super specialist’ expertise are important cultural barriers to challenging this kind of behaviour.
The recent launch of the UK version of the Choosing Wisely campaign 1 received much interest, and few doctors would argue with the principles of needing to be shrewder about how money is spent in the NHS. However, the decision for it to be coordinated by the medical Royal Colleges is an important one. This means the focus will be on each tribe of doctor self-identifying practices they consider to be of questionable value, and this will require an honest and critical attitude. Those individuals tasked with identifying these practices will need to be brave and challenge professional comfort zones, assumptions and ego.
The Choosing Wisely vision is a compelling one, and it would be a huge shame to miss this opportunity to rethink our approach to everyday clinical decision-making. The medical royal colleges need to take this on with the utmost resolution and confront all traces of arrogance and complacency. The perspectives of doctors in training, who are the newest members of each specialty tribe, must particularly be harnessed. They have the capacity to be a powerful force when it comes to developing a fresh approach and must be allowed to realise their potential as ‘agents for change’. 2
Although organisational and political levers are undoubtedly necessary to achieve cost savings in the NHS, there is also a considerable human element to individual clinical decisions. The Choosing Wisely tide has hit the UK from North America, and we must ride it bravely and boldly, challenging practices and egos to remove all traces of paternsalism and doctor-centredness. Holding a mirror up in this way will not be easy, but nobody said saving the NHS would be.