Time saving tips using the evidence
Dr Michael Taylor, GP in Heywood, past FDA Chairman, has turned the world of Evidence Based Medicine on its head. Naturally a modest man, he would not claim to be the inventor of Evidence Based Idleness but he certainly loves sharing a time saving tip or two with fellow FDA members. "The day job is busy enough!"
Dip your toe in the world of EBI and save time
Treat the patient not the investigation
“Treat the patient not the investigation”. I don’t know how many times I have said this to GP registrars, but it also bears repeating to more experienced colleagues. First up is a belter from the NEJM (2012;381:907-17) Mismatch between spinal MRI and symptoms of sciatica. This study compared patients one year after surgery for disc trouble or conservative treatment; there was no statistical difference. Then the authors took MRI Scans. Of those with residual symptoms 1/3 had evidence of a herniated disc, but then so did 1/3 of those without symptoms. In addition those with evidence of a herniated disc 85% had no symptoms, which was matched by the 83% of those without a herniated disc! So save time by not referring to the neurosurgeons unless there are red flags and by resisting MRI scans at one year. Such scans are notorious for finding abnormalities of dubious relevance that trigger a cascade of further tests and treatment.
Meniscal tears: surgery vs. physio
Anther goodie from the NEJM (2013;doi:10.1056/NEJMoa1301408) compared sticking a knife in to physiotherapy for meniscal tears in patients with a little bit of OA. Surprise surprise physio (n= 169) was just as good as surgery (n=161) at 12 months. Now what would be really exciting is leaving the poor patients alone and seeing what Mother Nature does unaided.
Domestic violence: find and treat?
I well remember the RCGP Campaign to find and “treat” domestic violence, we, then the SPA, even went so far as to invite the now RCGP President to give a presentation about the matter. Well the Lancet (2013, again, see we are bang up to date in the EBI office doi:10/1016/S0140-6736(13)60052-5) reports that treatment with brief interventions makes no difference to mental health, quality of life or safety planning and behaviour.
IAPT - CBT - DIY?
Now it’s the turn of IAPT, or Improving access to Psychological Therapies; how’s it going in your patch? Really I would like to hear. If you’re having difficulty getting CBT for your patients turn to Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data. (BMJ 16th of March 2013 p 12) In brief this says do what NICE tells you to do and send most to Step 2, for even if severe most do perfectly OK with the guided self-help. Our commissioners have reduced referrals to Tier 3 (CBT to 9% from 68% within a week!)