The clinical evidence boulder
An experienced colleague told me years ago that he didn’t routinely use his BNF. He was comfortable he knew what he needed. I was a little impressed, perhaps even envious, but then I thought: you know the information in there changes? I remain idealistic enough to hope that research in journals such as the BJGP and the guidance written in the BNF are intrinsically linked but it is undeniably Sisyphean to stay up to date; a relentless struggle to push the boulder of clinical care up an ever-steepening slope of evidence. Clinical update days can bridge the gap and remain wildly popular despite the death-by-PowerPoint style. Other than revalidation diktats, what motivates GPs to give up a Saturday for them? My guesses: complexity and fear. It’s the daily tyranny of the consultation in a world where the complexity of prescribing decisions has rocketed.
This feels like a pressing problem. How can we do it all and how do we define the limits of a generalist’s knowledge? Because let’s be clear on this — there are limits. Specialists can narrow their niche but we have no such mechanism. It was Nobel prize-winning economist and psychologist Herbert Alexander Simon who recognised the limitations of people to make rational decisions in the complex world. Our rationality is bounded. He came up with the portmanteau ‘satisficing’ to describe the process of managing complexity where people simply take what is offered if it satisfies and suffices. No more is needed.
Aldi and the paradox of choice
The bigger supermarkets have been apparently powerless to hold back the rise of Aldi in recent years.1 One might assume Aldi is popular because it offers value shopping. Personally, I think Aldi’s success is attributable to more subtle psychological forces that are in play: the Aldi effect is really about the paradox of choice. In line with Simon’s thinking, it has been shown that when we are faced with too many options we struggle. Psychologist Barry Schwartz documented the dizzying array of decisions we face when visiting the local supermarket and highlighted how too much choice is damaging to our wellbeing.2
One simple study showed this beautifully — participants had to pick chocolates from a selection. Some people had 30 varieties on offer and others had a more select group of six. Those with more to choose from took longer and were less happy with their choices — even when they ate the same chocolate as those with fewer choices.3 Performing exhaustive analyses is stressful and leaves more opportunity for regret. This choice architecture is not limited to consumers and plays out in modern medicine for doctors and patients.
Generalism suffers most from complexity
I suspect that happy generalists are strong satisficers. We are faced with more treatment choices, yet we have little additional time. It is astonishing how much we can synthesise, but how can we sustain evidence-based medicines values in the face of such pressures? This is real-world bounded rationality in all its ignominious glory; the world is just too complex for our individual ape brains. Bounded rationality is similarly a problem for patients. One of the contradictions of patient-centred care, pressing decisions on patients, is that they are exposed even more to the paradox of choice.
Clinical update courses are the Aldi of evidence-based generalism. They reduce the overwhelming complexity of evidence-based clinical medicine to manageable levels of choice. It may not be enough for the future and, for all my reservations about technology intruding on the consultation, we need help. I don’t feel any embarrassment dipping into a flowchart to unpick treatment decisions for diabetes or hypertension. These are, of course, basic algorithms. We have to recognise our limitations, and finding ways to integrate complex algorithms, even with their averagarian flaws, at individual consultation level may be unavoidable. Until then I’ll be keeping my BNF handy.
- © British Journal of General Practice 2019
