Intended for healthcare professionals

Fillers A patient who changed my practice?

The new Holy Grail

BMJ 1998; 317 doi: (Published 28 November 1998) Cite this as: BMJ 1998;317:1502
  1. Mark Gradwell, general practitioner
  1. Stockport

    E was an 87 year old man with chronic bronchitis and some deafness. He presented yet again with increasing dyspnoea. I listened to his chest for the expected wheeze. “Haven't really got much better Doc, started the steroids like you said and doubled my inhalers.” Then I noted in the background the irregular, rapid pulse. I congratulated myself for my clinical acumen in spotting his atrial fibrillation.

    For some time I had considered with unease the emerging evidence in favour of anticoagulation for older patients with atrial fibrillation. Audit within the practice showed only 60% of patients on any form of antithrombotic medication and most of these on aspirin.

    I attend a typically didactic lecture from a group of teaching hospital cardiologists presenting the case for anticoagulation with impressive statistics and apparent scientific rigour. At the end I voice my worries. Is the evidence from hospital based studies or have they recruited patients directly from general practice? Should I go back to my practice and anticoagulate all those elderly people who have never been anywhere near a hospital doctor? “Good question,” conceded the lecturer, “most studies are hospital based, but the hearts of your patients and mine will not be significantly different.”

    I am concerned he does not appreciate the increased frailty, multiple disorders, polypharmacy, tendency to fall, and mild confusion so prevalent in elderly patients managed in primary care and the subsequent impact on the safety of anticoagulation. Many of these patients are muddled about straightforward doses of digoxin, never mind warfarin with varying doses on different days of the week.

    So I speak to my local consultant geriatrician for advice. “I try to find a reason not to,” when faced with anticoagulation in the very elderly patient with atrial fibrillation, she says.

    I am pleased when E walks into the surgery one Monday a few weeks later. I felt that I had done well and not fallen into that common general practice trap of assuming recurrently presenting symptoms were due to his usual previously known condition. He looks grave as he hands me the letter from the emergency eye unit. Retinal artery embolus—“They say I should have been on blood thinners Doc.”

    Evidence based medicine is the new Holy Grail. But is the evidence really rock solid? If not, what makes us change our practice and reject well tried and trusted methods?

    Have I a unique perspective and knowledge of my patients in primary care, or has a doctor who has “fallen off the ladder” of hospital medicine no right to interpret the views of the experts when incorporating new evidence into my practice?

    This anecdotal experience has undoubtedly lowered my threshold for anticoagulation of these patients far more than the evidence base, about which I had some doubts. Is my practice now evidence based? Perhaps more realistically it is guilt driven.

    So now I know what I'll do when faced with this again, or do I? Today E presented with haematuria. Last week an elderly woman who I knew well died of a cerebral haemorrhage. She had presented to me with atrial fibrillation and an arterial embolus in a lower limb some four years ago. Ironically, she was put on aspirin by a registrar in vascular surgery; this was changed to warfarin only after I suggested this management option to the consultant. In a final twist of fate she collapsed on the way to her anticoagulant clinic.

    But, of course, soon I will no longer need to ponder these issues; the National Institute for Clinical Excellence will do it for me.

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