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Margaret McCartney: When can I get back to running after my operation?

BMJ 2017; 359 doi: (Published 02 October 2017) Cite this as: BMJ 2017;359:j4299

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Re: Margaret McCartney: When can I get back to running after my operation?

I wonder if McCartney missed an alternative approach to finding out what is best advice(1)?

At a fundamental level, it is recognised that in general RCT derived guidance, if followed results in sub optimal treatment and recovery in almost all patients (2). However, where local practice is based on what produces the best outcomes locally: Often starting from nation guidance.

One mechanism to this is in a QIC (Quality Improvement Collaborative) (3) then outcome results are generally significantly and clinically importantly better at a population level, and though practice varies (as her piece suggests it does in this case) this actually improves population outcomes despite the differences between centres (4)!

I recognise this is counter intuitive, but the evidence really does suggest well informed clinical judgement based deviation from national or regional guidance is probably better for patients than treating them as all identical widgets!

So I disagree that producing nationally standardised leaflets is a good way to go. As we recently pointed out in the Journal of the Royal College of Physicians of Edinburgh there are both staff and patient benefits from following this route (5), not to mention very large medium term cost reductions. But unless the one size fits all approach (population wide uniformity) is abandoned by those in power then we are condemned to increasing cost, poorer outcomes, lower staff morale and productivity, and widening inequity in outcomes.

1 McCartney M. Margaret McCartney: When can I get back to running after my operation? BMJ 2017: j4299.
2 Rothwell PM. External validity of randomised controlled trials: “To whom do the results of this trial apply?”. The Lancet 2005;365: 82–93.
3 Berwick DM. Broadening the view of evidence-based medicine. Quality & safety in health care 2005;14: 315–6.
4 Eppstein MJ, Horbar JD, Buzas JS, Kauffman SA. Searching the clinical fitness landscape. PloS one 2012;7: e49901.
5 Temple M, Pontin D. The case for using an evolutionary professional protocol for improving care: act local, think global. J R Coll Physicians Edinb 2017;47: 10–2.

Competing interests: No competing interests

09 October 2017
Mark Temple
Retired Public Health Physician