The charge often leveled at general practice, at least in the UK, is that we never change. To anyone with a memory going back further than the last few years, it's laughable. But there is a virtue in a conservative approach to clinical life; we are not swept up in every latest fad, nor do we act on every significant research finding, or prescribe every latest drug.
Then every so often something truly arresting comes along. So for me, learning that psychosis in young people has such a dramatic effect on life expectancy (page 395) is shocking and not to be ignored. Not that in this case it's clear what we should be doing about it. The editorial is linked to a report of an intervention to help GPs improve their handling of psychotic patients (page 403). The numbers referred to specialists were no different between intervention and control groups, but the intervention group of GPs did refer earlier in the illness, perhaps as a result of the education that went with the package. The trial, however, was dealing with short-term outcomes (a problem common to so much of published research). Most messages have less immediate impact, and need several repetitions before they strike home.
On page 428 there's another paper on the difference in blood pressure readings between the two arms — here among patients with diabetes, and with the suggestion that a bigger difference might in itself be a risk factor for vascular disease. We have published two papers on the same subject quite recently,1,2 yet so far I haven't personally responded to the message in my clinical practice. But the weight of evidence is accumulating, and in an echo of the Bellman in the opening stanzas of Lewis Carroll's Hunting of the Snark (‘What I tell you three times is true’), now that I've heard this one three times it's time to change. But wait a moment — are my blood pressure readings good enough?
The study on page 422 reports on assessment of peripheral vascular disease. The ankle/brachial index measurements in primary care were compared with those in a specialist unit, and the study found significant variability between the two sets of readings. The study plotted the results on a Bland-Altman plot, and the linked editorial by Douglas Altman on page 399 sets this into a wider perspective, reviewing the tests we should apply to all new methods of measurement. He ends with the warning that statistics cannot provide perfect answers but can ‘… provide a meaningful summary of the evidence … to inform clinical judgement’, a reminder that we should never trust any method to give infallible answers.
We've also published papers in the past that have involved patients in the planning or conduct of the research. On page 415 there's a fresh take on this, with an account of involving patient groups in drawing up guidelines that are to be tested in further studies. The editorial we published last month on guidelines acknowledged that they are sometimes not sensitive enough to the needs of individual patients,3 and this looks like an attempt to address that need quite specifically. The editorial on page 397 summarises the history of patient involvement, and articulates the arguments that should command unquestioning acceptance; at the same time it warns against tokenism: ‘inviting involvement can only be justified when patient or public expertise is required and can make a difference.’ Pursuing the same goal of more attention to patients' individual needs, the essay on page 454 argues for a complete change in our attitudes to what we prescribe. Here is a change that speaks for itself but whose implementation may take much more than repetition three times over. I must confess, however, that the most arresting part of this was the opening quotation, which stopped me completely dead in my tracks. One for everyone's commonplace book.
Equally striking is the report in the leader on page 401 that internet users are downloading articles from the BJGP's electronic archive at a rate of more than 700 000 per year. This figure is so astonishing that I simply didn't believe it when I first read it. Only it seems to be correct. It evokes an odd mixture of puzzlement, surprise, but also pride (I hope forgiveable) that there are so many people out there who want to make use of what we produce.
- © British Journal of General Practice, 2009.