MANY years ago I was told this joke about doctors and patients: a man lies dying in his bedroom, attended by his wife and doctor. His breathing becomes slower, and then seems to stop altogether. The doctor turns to the wife: ‘He's gone’. At which point the man rallies: ‘I'm not gone yet’, to which his wife replies: ‘Shh. Doctor knows best.’ ‘Doctor knows best’ has a wonderfully dated ring to it. It simply is not a phrase heard very often these days. Mike Fitzpatrick (who has taken on the responsibility of articulating unfashionable ideas) argues on page 405 that we need to remind all those keen to overlook the fact that we are experts in clinical medicine, the products of many years education and experience. The charge of paternalism may have led us to collude in devaluing our own expertise.
The loss of confidence is compounded by the eagerness of the managers in the National Health Service (NHS) to devise clever new solutions to problems that we have been grappling with for years. This month we are publishing several papers looking at the question of access to services. The review on page 374 explores the various initiatives that have been introduced in the last few years to improve access to primary care. Sounding a familiar note, the authors conclude that the evidence overall is insufficient to make clear recommendations where efforts should be concentrated in the future. The poor quality of evidence available to support recent costly innovations is echoed by Chris Salisbury's editorial on page 330. The review takes care to explore different aspects of access (see Box 1 defining the different components) and it becomes obvious that emphasising one component may work to the disadvantage of others. For instance, some of the new schemes improve overall availability but with no improvement in equity. The NHS's latest suggestion to improve access is the Advanced Access scheme, whose success is examined on page 334 and page 364. The tentative verdict is that the scheme can reduce the time of waiting to get an appointment by a modest but significant amount, but with patients thereby having less opportunity to plan to see the doctor of their own choice. A similar finding emerges from the report of a single practice's experience on page 367. Here patients who booked appointments in advance were more likely to see the doctor of their choice. The patients were also able to negotiate their way through a mixed system, so that reducing the range offered may not be answering the needs of all patients, at least in this one practice. If this strikes many readers as a glimpse of the obvious don't be too dismissive. It's simply another example where doctor may know best.
On the other hand, doctors also attend to their own interests: knowing best may mean knowing what is best for themselves, rather than the patients. On page 397 Patrick Trust argues that increasing centralisation of hospital services is not in the interests of patients in rural communities and sends the warning reminder that such concerns can become important at elections. For an outsider's view on the NHS turn to Andre Kruger on page 398. This makes for uncomfortable reading, but he for one is certainly of the view that control from above is reducing doctors' responsiveness to patients, not improving it.
Before we let complacency take over altogether, we carry some reminders of lapses from perfection: knowing best does not amount to infallibility. The editorial on page 331 reminds readers how often medical accidents take place. It discusses some of the steps taken to improve matters in specific areas, and offers what is potentially a much more helpful, supportive model for reducing error in the long term. It also turns out that we are just as bad at recognising mental illness in children as we are in adults, if not worse (page 348). Performance here was much improved by the parents' voicing their own concerns, but all too often that didn't happen, and the doctors' ability to facilitate such disclosure may be all important. But I can hear the distant echoes of the doctors who tried to teach me paediatrics telling me that all we had to do was listen to the parents. Another eternal verity to remember.
- © British Journal of General Practice, 2004.
