Clinical encounters in the post-guidelines eraBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3200 (Published 27 June 2016) Cite this as: BMJ 2016;353:i3200
- Glyn Elwyn, professor1,
- Siestse Wieringa, research fellow2,
- Trisha Greenhalgh, professor3
- 1Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire 03755, USA
- 2Institute of Health and Society, University of Oslo, Oslo, Norway
- 3Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Correspondence to: G Elwyn
Jan is a 42-year-old plumber, originally from Poland. He tells his family doctor that he’s had low back pain, going down the back of his leg and making it painful to walk. He takes drugs for psoriasis and high blood pressure. He smokes five cigarettes a day (down from 20 a year ago). He went through a long period of depression after his first child was stillborn three years ago and still has days when he feels very low. He and his wife are keen to have another child but she has not become pregnant.
Amanda has been Jan’s family doctor for many years. She works full time, typically seeing 30 patients a day and doing much of the administration. She went on a one week update course recently, in which specialists presented the latest evidence on 15 clinical topics. She sees the occasional pharmaceutical representative and skims the abstracts in two journals regularly. She is a member of an online social media (Facebook) group where she shares ideas and (with consent) fragments of real patient cases with her peers. She joins this group twice a day and finds it a source of usable knowledge and support.
The various guidelines relevant to Jan’s acute and chronic conditions exceed 500 pages.1 2 3 4 5 6 7 Amanda does not consult any of these guidelines. An experienced practitioner using knowledge that is primarily intuitive and applied through heuristics (rules of thumb),8 she asks Jan a few questions about his back pain and examines him. While doing so, she notices that his psoriasis is quiescent and also checks his blood pressure. She offers him non-steroidal anti-inflammatory drugs and asks him to return in a few days …