HEALTH / Second Opinion

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The Independent Culture
SHOULD your doctor be free to choose whatever treatment he believes is best for you? This question would have astonished medics from an earlier generation: as recently as 20 years ago both general practitioners and hospital consultants were truly independent decision-makers, and eccentrics were tolerated by their colleagues. I remember one surgeon who gave his patients whisky (by stomach tube, so that they wouldn't enjoy it) to improve their circulation.

But times have changed. The treatment of common conditions as various as infertility and severe asthma is laid down by groups of experts - often research workers or university teachers - who draw up a set of 'guidelines' based on clinical trials that set out in considerable detail how a patient should be treated, which drugs should be given and which tests made. All the doctor has to do is to get the diagnosis right, key it into his computer, and the current top choice treatment will scroll out on to his desk.

That is the theory, but despite all the guidelines doctors and patients still go their own way because they have their own beliefs. For example, research studies have established that someone who suffers a coronary thrombosis is most likely to survive if clot- dissolving drugs are injected as soon as possible. If GPs don't have the drugs with them they should send patients to hospital at once - meanwhile giving them an aspirin to make the blood less sticky. In reality GPs seem unwilling to use these drugs, possibly because of concern about cost and possible side-effects, doubts about whether the treatment makes much difference, or even because it is easier to hand over responsibility to the hospital. But why won't they even give the aspirin (only one-fifth did so in a recent study in the British Medical Journal)?

It may be that doctors are inherently conservative. It isn't just GPs who resist advice on what to do: more than 10 years after experts agreed that surgeons should give patients heparin to stop blood clots forming in the veins, by no means all do so. Doctors are slow to change and many still wish to make up their own minds. So, of course, do patients. In a world in which only the standard treatments were given, what hope would a patient have of being treated by acupuncture or homeopathy on the NHS? Patients can, indeed, be very determined; in the 1980s some sufferers from multiple sclerosis believed they would benefit from treatment with high-pressure oxygen, but most neurologists were doubtful. The patients raised the money to buy and install the expensive equipment and got their treatment, though sadly it proved of little long-term value.

A balance is needed. When the patient and the doctor believe in a treatment, it has a good chance of working - even if experts disapprove. But specialist clinics do get the best results, and other doctors should usually follow the treatment specialists recommend. The concept of medical audit has now become accepted, and individualistic doctors may have to get used to justifying their views. The anxiety is that those twin modern demons, the lawyer and the accountant, will together force doctors always to comply with treatment guidelines - whether or not that is what they and their patients want.