The Back Pages viewpoint EBM and the future general practitioner VER since evidence-based medicine (EBM) erupted onto the scene in the mid-1990s it has evoked strong passions, both for and against. Among general practitioners, there “The central idea of an Eare enthusiasts (with whom I unashamedly identify)1,2 and sceptics (with whom I am happy to debate).3,4 The resulting dialogue has played an important part in moving forward ecosystem is that ideas about how to integrate the process of EBM into our practice while preserving a humane, organisms living in an patient-centred approach.5-7 For enthusiasts, the integration of EBM into general practice area ... should be now seems essential for its future development.8 Yet, sceptics sometimes seem to reject the idea that any good can come of it at all. considered together with other organisms I agree unreservedly that the doctor patient relationship and the art of medicine are essential and their environment components of good general practice. I also agree that it would be a disaster if clinical practice was reduced to ... a mechanistic rulebook [following] evidence-based guidelines .9 as an integrated However I profoundly disagree with the conclusion that the practice of EBM by GPs would interacting system of lead to such a dire outcome. co-evolving elements.” EBM at the individual patient level is a process in which ... knowledge of epidemiological The NHS as an ecosystem principles [sheds] light both on the illnesses of patients and on the diagnostic and Peter Dick, page 248 management behaviour of their clinicians [and that] applying these epidemiological principles ... to the beliefs, judgements, and intuitions that comprise the art of medicine might “ substantially improve [clinical management and the teaching of medicine] .10 In other words, what ten non-medical it is an addition to our established clinical skills, not a replacement for them. There remains, books (to) recommend of course, much work to be done on how to integrate these new skills into the consultation, to aspiring GPs but that would be so for any innovation. today?...” 9 Nevertheless, Charlton s nightmare scenario is by no means a figment of his imagination. Osler’s Books There is currently a plethora of top-down guidelines imposed upon GPs by expert groups and John Gillies, page 251 organisations, such as the National Institute for Clinical Excellence (NICE). The fiasco of the zanamivir (Relenza) guideline is a demonstration of what the editor of the BMJ called the “ corruption of EBM .11 The appropriation of EBM by such groups, that take a population an indispensable rather than an individual patient view of clinical effectiveness, is a real threat to humane information source for clinical practice, as it puts pressure on clinicians to fit patients into predetermined categories the cultured traveller” rather than listening to them to take account of their unique needs and values. Benny Sweeney finds solace, page 252 The necessary (but probably not sufficient) condition to protect patients from impersonal, bureaucratic, clinical management is for clinicians to learn the skills of EBM themselves contents rather than leaving it to the experts . This is partly a matter of using evidence in such a way as to make better and more focused clinical decisions in the context of the patient s needs and 242 news values ( bespoke rather than off-the-peg medicine), but it is also a matter of power. The Pesticides/human nutrition/Belfast ability of GPs to practice EBM represents an enhancement of their expert power relative to 244 miscellany guideline-generating bureaucracies , and thus their ability to act as advocates for their Cuban general practice 2,12 John Waller and Graham Watt patients and practice Cum Scientia Caritas. 246 postcards from the Toby Lipman 21st century Supra-practice organisations References Geoff Meads 1. Dawes M. On the need for evidence-based general and family practice. Evidence-Based Medicine 248 essay 1996; 1: 68. Beyond markets and government: 2. Lipman T, Rogers S, Elwyn G. Evidence-based medicine in primary care: some views from the 3rd a Third Way for Primary Care UK workshop on teaching evidence-based medicine. Evidence Based Medicine 1997; 2: 133. The NHS as an ecosystem 3. Sweeney K. How can evidence-based medicine help patients in general practice? [Editorial.] Fam Peter Dick Pract 1996; 13(6): 489-490. 250 digest and reflection 4. Jacobson LD, Edwards AG, Granier SK, Butler CC. Evidence-based medicine and general practice McWhinney on neo-Balintism, (see comments). Br J Gen Pract 1997; 47(420): 449-452. Howie on patterns of work in 5. Greenhalgh T. Narrative-based medicine: narrative-based medicine in an evidence-based world. primary care, Osler’s books, BMJ 1999; 318(7179): 323-325. Thistlethwaite assesses two 6. Elwyn GJ. So many precious stories: a reflective narrative of patient-based medicine in general novels on extreme disability, practice. BMJ 1997; 315(7123): 1659-1663. Minns drooling over Caravaggio, 7. Lipman T. Evidence-based medicine. [Letter; comment.] Br J Gen Pract 1997; 47(422): 591-592. Sweeney gadding about...plus 8. Lipman T. The future general practitioner: out of date and running out of time. Br J Gen Pract 2000; tales from newfoundland 50: 743-746. 254 matters arising 9. Charlton R. The future general practitioner. Br J Gen Pract 2001; 51(462): 66. January Council 10. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical 255 diary and medicine. 2nd ed. Boston (MA): Little, Brown & Co., 1991. goodman on being read 11. Smith R. The failings of NICE. BMJ 2000; 321(7273): 1363-1364. 256 our contributors 12. Lipman T. Power and influence in clinical effectiveness and evidence-based medicine. Fam Pract and Thistlethwaite 2000; 17(6): 557-563. The British Journal of General Practice, March 2001 241 Pesticide-related ill health seminar for general practitioners on was first widely used as a pesticide in the the diagnosis and treatment of 1940s, now contaminate every point in the Apesticide-related ill health was globe, including our own bodies. In doing organised last year by the Pesticide Action so, he described the context in which family Network UK, a non-profit-making group. doctors now work: The seminar, which was held in London in September, was borne out of frustration. Persistent chemicals have a half-life in our body, which means that we metabolise them The Chief Medical Officer issues reminders more slowly than we take them in, so that at regular intervals that GPs should report the body burden increases as we get older. any exposures to pesticides and veterinary The body is able to get rid of other medicines. However, both the Department of chemicals, such as organophosphates and Health and the Royal Colleges have carbamates, relatively quickly, within about acknowledged that GPs are not well 72 hours. We come across them every day equipped either to investigate or to diagnose through a variety of routes, primarily food. pesticide cases. Training for doctors on organophosphate poisoning was a Whether or not children, in particular, are at recommendation in the 1998 report by the risk from the deliberate routine use of Joint Working Party of the Royal College of endocrine-disrupting pesticides in the food Physicians and the Royal College of chain must be considered , said Dr Howard. Psychiatrists. However, this has been He reminded delegates of the government ignored. guidance to parents to peel fruit and vegetables, to reduce children s exposure. It And what of the centres of expertise for was based on work carried out by the supporting doctors that the Royal Colleges Pesticides Safety Directorate which found also acknowledged were needed? The that the acute reference dose (the safe dose Department of Health has now cut the for one meal or one day) could be grossly funding of the only existing institution that underestimated because of variations of might have formed the basis of such a particular pesticides found on different network: the National Poisons Information individual items of produce. Children could Service (NPIS). receive six or seven times the acute reference dose if they ate the wrong sort of Whether the NPIS fulfills the expert role fruit on the wrong sort of day . envisaged is in any case questionable. Long- term effects of exposure can only be Professor Andrew Watterson, of Stirling assessed if toxicovigilance is carried out: University s Occupational and NPIS London itself admits that this is a Environmental Health Research Group, much neglected area. Emerging argued for better occupational health epidemiological evidence about pesticides is surveillance systems to be embedded in not being effectively disseminated to the forthcoming Health Improvement profession. Programmes. He drew attention to the Ministry of Agriculture s Pesticide Usage The argument that doctors rarely see cases of Survey, from which information on the pesticide poisoning was not accepted by pesticides used in a particular area is delegates. In fact, as Dr Vyvyan Howard available. This could be useful to GPs if (Foetal and Infant Toxicopathologist at the they are seeing many cases of, for example, University of Liverpool) described at the breast cancer . seminar, every patient a GP sees has been exposed. Pesticides are used, not just on More courses and materials are planned farms, but in homes and gardens and by which can be used by individual Primary local authorities. Care Groups and other health professionals within the Health Improvement Programme Dr Howard s main concern was that framework. chemical combinations and their effects are not being tested for in the regulatory control Alison Craig systems, based as they largely are on the conventional model of toxicology in which a single linear dose-response effect is measured.