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Tick Box Medicine

Posted by Dr No on 21 March 2010

fatty.jpgDr No’s mother, a fit 80-something year old, recently attended an ophthalmology clinic, on the advice of her optician, and was told – out of the blue, by a nurse – she hadn’t even seen a doctor - that a bed had been arranged for her to come in two days later to have her cataract removed. The nurse was most put out when Dr No’s mother – who knows her mind very well – said she had no intention of coming in for an operation she neither knew about, nor did she need. Yes, she does wear reading glasses – but otherwise her eyesight is fine.

Last month, the ‘parent/carer’ of Cian Attwood received a letter from an NHS ‘systems manager’ warning that Cian was ‘very overweight – doctors call this clinically obese’, and could grow up with ‘dangerous amounts of fat’ in his body, before adding gleefully - presumably to ram the point home in case the ‘parent/carer’ had failed to appreciate the danger Cian was in – that he was at risk of cancer, diabetes and heart disease, and that ‘some of these can begin in childhood’. Cian does indeed have a high BMI – but he is not in the least bit obese.

These are but two examples of tick-box medicine, that growing parallel clinical world in which pseudo-doctors make pseudo-diagnoses and prescribe all too real treatments based not on clinical reason, but on protocol. The trouble is, the human body doesn’t ‘do’ protocol. People vary, but protocols don’t – which is why they come unstuck.

As a medical student, Dr No was taught to treat people not diagnoses. The person in bed six was not ‘the breast cancer’, but Mrs Jones, whose cancer affected her in her own unique way. In the same vein, he was taught never to consider a test result in isolation; instead, a test was always interpreted as part of the broader clinical picture. A BMI that might suggest obesity in one patient might just as well reflect high muscle bulk in another. It is only by considering the patient in the round, so to speak, that the true picture will emerge.

Doctors, who from their first day on the wards are taught the art of diagnosis, do this naturally. They expect to see the patient, and interpret in context. If Cian is evidently slim, then he is not obese, whatever the BMI says. Systems managers, and the other myriad lackeys who work in today’s NHS, interpret by protocol. If the BMI says obese, then the patient is obese.

Doctors, of course, do not come cheap, partly because they have spent many long years learning how to think, such that their reasoning is soft-wired; and they can handle the exception, because the protocol is only loosely embedded in their head. Systems managers, armed as they are with their tick boxes and their protocols, are hard-wired, and will brook no exception. They may be cheaper in the short term, but by the bigger picture, they will turn out – not always, by any means, but too often for comfort - to be an expensive mistake.


Now at the beginning of this post I thought it was going to be another example of rationing, or worse, ageism, in the NHS.

In other words I half expected to hear a predictable and slightly depressing tale of prolonged waiting times before an elderly patient received appropriate care - but no, surprisingly treatment and admission were both offered, and all within 48hrs - hooray, a happy outcome at last?

But wait - it seems incompetent nurses are arranging surgical procedures for non-existent opthalmic conditions?

The all pervasive protocol seems to have robbed these rogue quacktitioners of even the most rudimentary form of common sense, including a disregard for the optician's examination which presumably found no significant problem with the lens?

Who on earth devised a protocol recommending surgery on healthy eyes?

A&E Charge Nurse - Crippen may have pegged it, but Dr No isn't going to jump into quacktitioner-busting with quite the same fervour (unless, that is, they deserve it, in which case his zeal will exceed Crippen's).

The point in this post is that protocols (not those who operate them, who are but puppets in the hands of the protocol) fail because they can't accommodate outliers - normal people who have an abnormal result. The only way to guard against the gaffs is to have an intelligent human (otherwise known as a doctor) involved.

Dr No still doesn't know how the protocol arranged his mother's admission. She was so busy being feisty that she didn't actually ask why she had been booked for admission. What's much more worrying is that if the patient hadn't known her own mind, then she could easily have ended up having an operation - with all its attendant risks - that she did not need.

Yes, I will certainly miss Dr Crippen - I guess we blog addicts will be looking to you, Dr Grumble and JD to feed our habit?

Dr Pal expects great things from you - I'm sure you won't disappoint her ;o)

BMI values don't apply to children, as any fule kno

One or two doctors are finally beginning to wake up to the perennial limitations of the model being lauded here.

In Atul Gawande's book "The Checklist Manifesto" he offers two analogies to highlight why medicine has failed to develop appropriate mechanisms for dealing with predictable risk.

Gawande (who is a distinguished surgeon) recounts how, in 1935, crew members died during the first test flight of the 'flying fortress'.
The fatal crash resulted from pilot error - Major Hill, who was considered to be one of the air-forces finest pilots, forgot to release a new locking mechanism on the elevator and rudder controls (p33).
Flight protocols followed in the wake of this preventable catastrophe - if a pilot with Hill's formidable talents could not totally eliminate risk what other option was there?

Gawande's second analogy is drawn from the building trade.
How is it possible to construct gravity defying buildings like the World Trade Centre?
We hear about the days of the medieval 'master builder', a role slowly replaced by a host of separate specialists bound by a complex set of checklists and protocols.
Where such systems exist (in aviation and construction) far fewer errors occur compared to medicine.

Finally Gawande claims professional codes usually encompass x3 elements;

BUT (according to Gawande) what is lacking in medicine is a fourth element, DISCIPLINE - and what he means by this is rigorous adherence to the mundane.
He states - "In medicine we hold up autonomy as a professional lodestar, a principle that stands in direct opposition to discipline. But in a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips ANY ONE PERSON'S ABILITIES, individuality hardly seems the ideal we should aim for. It has the ring more of protectionism than of excellence" (p183).

To my mind the kind of cavalier vs roundhead distinction suggested here simply does not exist. There are either those who understand risk, in the myriad forms it can take, and those who don't.
Neither camp is doctor or quack exclusive, and obsession with a particular skill (diagnosis) however important this skill may be, can only doom those who adopt such a posture to repeat time and again the same, predictable set of mistakes ......... after all, diagnosis is only one part of a much broader array of complex circumstances?

It is somewhat disingenuous to assert that tick-box medicine is solely the preserve of non-doctors.

With the introduction of QOF, many primary care doctors practise tick-box medicine. Similarly it is not unknown for hospital doctors to only investigate according to protocol rather than according to patient need.

Doctors are not immune to point-scoring and back-covering.

Anon at 7:28 - an interesting point, on which Dr No is a fule, in that he is not a paediatrician. But does seem possible (and it has certainly been done - see here) to take bunch of normal kids at various ages, measure their BMI, and plot the results. Interestingly, and possibly even relevantly, (a) the curve is J shaped, with a nadir at around Cian's age, (b) the distribution appears skewed (towards higher BMIs - perhaps because it is an American sample?) and (c) the overall range is lower at younger ages. So - it would seem possible to define a what percentile a certain child is on. Whether that has useful general clinical meaning is another matter. Certainly, in Cian's case, it did not.

airplane.jpgA&E Charge Nurse - a very pertinent point. I am sure we would all prefer our pilots to follow a checklist before take-off, rather than follows flashes of professional brilliance in deciding what to do and not do. However - airplanes and buildings are physical objects that follow the laws of physics, whereas humans - to put it crudely - are biological, and follow biological laws, one of which is about variability; and so medicine has to be able to accommodate that variability.

The traditional answer has been to train doctors in the art (and it is salient that it is called an art and not, as one might expect, a science) of diagnosis. As I said in the original post, doctors expect to see their patients, and interpret in context. I can't see any other way of accommodating natural variability. Certainly an office bound 'systems manager' with a BMI protocol can't; nor can a ophthalmic nurse with a clipboard.

I take Gawande's point that autonomy and discipline don't sit at all well together - particularly in complex procedures involving many disciplines - but I am not saying that doctors should be autonomous loose cannons that do whatever they like. Instead, it seems to me that they are the professional group who, because of their training, are best placed to accommodate natural biological variability.

Anon at 10:48 - I could not agree more that many GPs are turning into tick-box doctors. It is deplorable. The GPs will say it is not their fault - they are only responding to 'incentivisation'. That is as may be: it is still deplorable.

I just know that the weight/height squared formula doesn't work for children as they are relatively short for their weight (compared to adults), the numbers are skewed incorrectly towards obesity. You assess obesity in children clinically using the mark 1 eyeball.

Anon at 7:28 - I agree about the importance of the Mark 1 Eyeball - that is why the original post contains 'They [doctors] expect to see the patient, and interpret in context' - doctors see patients so they can use the Mk 1 eyeball. Those who practice tick box medicine spend their time looking not at the patient, but at the form they are filling in.

I'm interested that two comments have said BMIs don't work for kids. It seems to me statistically possible, and indeed meaningful, to measure kids' BMIs and plot them on a chart (OK it is an American sample but it is CDC so should be sound enough):


The plot appears valid as a statistical exercise (and, looking at the percentile spread/range at any particular age, it does appear skewed towards higher BMIs ie obesity, and that skewness also increases with age ie the kids get fatter as they get older - it is the USA after all).

Is it the case that however statistically sound the exercise is, clinically it has no merit because BMI in kids is not (for whatever reason) a proxy for real world obesity? If that is the case, what on earth are Telford and Wrekin NHS Specialist (sic) Services for Children and Young People doing using it? Dr No smells bad medicine...

Do accepted BMI cut off values exist for children? I don't know, I've never seen any and I doubt the nurse in question has either.

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