Fortnightly Review: Commentary: The perils of checklist medicine

This paper has a logic and clarity that does not seem to belong in the messy world where I and my patients strive, often against daunting socioeconomic odds, to be “co-producers of health.”1 The honourable intentions of the authors are evident, but the notion of defining and using criteria with which purchasers can monitor compliance with agreed guidelines implies levels of coercion and control which are potentially destructive of the fragile good that is the doctorpatient relationship.2 Guidelines are constructed from evidence from research derived from studies of populations and are predicated on the notion of a composite patient which may have little immediate relevance to the troubled person who presents in the consulting room.3 In hospitals, diseases stay and patients come and go; in general practice, patients stay and diseases come and go. Guidelines depersonalise individual patients and turn them into diseases even in general practice.

The authors give a single example of what a review criterion will look like in reality. As far as I understand it, the evidence from research is that excessive intake of alcohol increases the patient's risk of raised blood pressure. This becomes translated into a review criterion with the suggested wording “the records show that annually the patient has been advised to limit weekly alcohol intake to less than 21 units if male and less than 14 units if female.” I have objections at two levels. Firstly, there is evidence of the role of excessive alcohol in the aetiology of hypertension, but I am not aware of evidence to support the contention that advising patients annually to limit their alcohol consumption improves the control of raised blood pressure, let alone that a note in the records to this effect has any impact. Surely, this is to confuse process with outcome. Secondly, patients may resent the imposition of the doctor's agenda for the consultation at the expense of their own. The doctor will feel compelled to give this advice repeatedly and increasingly mechanistically whether the patient is a longstanding alcoholic or a renowned teetotaller. A year is a short time in general practice, and patients who never drink will not take it kindly when their doctor reminds them yet again of the perils of excess. The patient will be concerned about both the memory and the sensitivity of the doctor. At the other end of the range, an alcoholic patient often faces social and economic problems which render the risks of hypertension unimportant. Will he or she be helped by being repeatedly informed of the recommended limits?

Patients, perhaps even more than doctors, make many perverse decisions. They persist in smoking and drinking to excess despite being aware of the risks to their future health; they refuse to comply with medication and technology, such as hearing aids, of proved efficacy. This seems to suggest that health, narrowly defined as the absence of disease, is not the preeminent aspiration of human endeavour.4 Doctors, managers, and politicians need to recognise that self determination, dignity, and autonomy are important components of a wider definition of health and that personal and socioeconomic pressures can make longevity less desirable.

Guidelines and review criteria can contribute to the pursuit of quality in clinical care, but if politicians and purchasers seek to implement them without acknowledging the complexities of realclinical settings they may do more harm than good and consume huge resources in the process.5