AIBU to think that most people want clinicians and our wider system to have real autonomy?

[GEEpEe]

So I have a medical issue. Repeated pilonidal sinus. Common on hairy men who sit a lot. I'm a GP and hairy so that is me.

Laser treatment has been shown to reduce the reoccurance rate in some patients but not enough for the NHS to fund the treatment.

It's one of those things where if you have the obvious risk factor of thick, plentiful body hair and when they operate, they're removing copious amounts of said hair from the tunnel created, lasering that individual seems to make sense.

But as clinicians, we are so tied to protocol about who meets the criteria for referral/treatment and I know myself that you get shit from higher up when you don't obey. I'm known as a maverick and rebel but all I can really do in most cases like mine is refer and make some sort of suggestion of such a treatment in the notes.

I could afford private lasering but I've been trying to "fight" the CCG to let clinicians make individual decisions about who might benefit from lasering to no avail. Now I've had quite extensive surgery and my wife is putting her foot down and saying I've got to get my whole arse lasered but that's another thread!

My question is wouldn't you prefer overall if your GP and specialists could make individual decisions about what treatment might work for YOU based on available evidence and personal values and goals rather than just stats from RCTs that make blanket rules about who can get what?

Obviously because stroppy, persuasive and persistent buggers like me will get what we want. Would that lead to greater inequality of provision? Not that’s it’s equal at the mo ...

No. Because self-describes “Mavericks” tend to view the lowest level of evidence (personal opinion) as being superior to the highest level (review and meta-analysis).

As a GP you know that guidelines based on evidence are important. They already have the facility to argue for certain individual cases, eg breast reduction, so I think your question is phrased incorrectly.

Because vulnerable people will lose out because of individuals perceptions. I work with people with learning disabilities and this already happens - clinicians make judgements on quality of life and say the treatment wouldn't be appropriate etc. (This is massively simplifying the issues) It's easier to discriminate and give preferential treatment if there aren't clear boundaries on treatment.

Not to mention the pressure this puts on the service you are referring to.. surely they will get a say and prioritise what's going to be more effective.

Considering you work in the nhs why are you not aware that they cannot afford to fund all treatments for all people?

I think sometimes personal opinion (particularly the patients) does outweigh statistics myself. GPs are the gatekeepers of specialists in most cases. We are instructed to not refer if the patient does not meet a specific and subjective criteria. So sometimes, someone will be in pain, telling you that pain relief is inadequate and because they don't meet some criteria of a test or referral, they just have to live with the unknown cause.

They don't tell you to do that, but there is often no guidance on what to do when someone doesn't meet criteria for referral but still has an issue which you can't quite work out.

That's why so many people live with badly managed chronic pain..

Dont get me wrong, RCTs are important. All research is important. But you have to think of the individual too. All research has outliers. What about when you're one of those?

Tonsillectomy referral in my old practice for kids requires 5x tonsillitis in 2 consecutive years. So a kid has to pretty much have chronic tonsillitis for 2 years to get referral.

I've had a temporary condition for over 20 years I'm an anomaly in the statistics I should still get treatment though but I slop through the cracks due to my anomalous nature I get given tablets and go for the odd blood test no one knows how I will cope if/when it reverts

No, I prefer my HCPs to follow set guidelines by the CCG and refer patients that fit the criteria. I don't think there is any place for 'mavericks' in the NHS .

@slipperywhensparticus
.do you think that's okay?

Agree OP. But also a clinician in the NHS...

I'm maverick in that I don't try and talk women out of tubal litigation or will order a scan for someone with vague and moderate to mild intermittent back pain outside of protocol. That's what makes me rebellious. Listening to patients and taking their complaints seriously.

I think that if we could tailor treatment to patients, we would save money overall because problems would be fixed rather than masked.

I think that treatment should be based on individual clinical/medical need, and that HCPs should be able to take a decision on a case-by-case basis and not have their hands tied by arbitrary rules.

Why don't you just go and get your arse crack waxed?

Like women who keep going for bikini waxes.

Laser treatment isn't risk free. Burning, etc

You know when there is a less risky option that is freely available and would solve the problem, you should take it right. You're a GP after all.

Waxing doesn't have the same reduction of reoccurance rate

You could have been having it waxed for years.

Laser treatment isnt exactly pain free

But you could try...

I want I want

I have PCOS but don't qualify for laser hair removal and my gp wont prescribe vaniqua because it's too expensive

Just like a man to sit and say I want

Waxing doesn't have the same reduction in reoccurrence rates. In fact in some people it makes it worse due to ingrown hairs which is essentially what a pilonidal cyst is

PCOS is another condition that I think warrants laser hair removal actually. But they calculate based on every single patient with a diagnosis wanting it.

In my imagination, clinicians should be trained in all the medical gubbins (‘gubbins’ being the technical term for all the training 👍🏼) plus critical thinking and analysis, and then given a framework to operate within that allows for clinical judgement based on available evidence and the patient in front of them.

I’m a person, not a number or a statistic.

It’s not, and can never be, one size fits all.

Considering I cost the NHS money last week after being hospitalised with sepsis post surgery, maybe lasering my hairs would free up some money long term for chairs in the oncology unit.

I think that's disgusting. If your son needs a tonsillectomy, he should have it on the NHS.