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?

In terms of tonsillectomy, research shows that many kids grow out of the repeated occurance. Enough grow out of it over time for them to think you need to get it several times in one year and then the next.

The research doesn't seem to counter the pain and discomfort suffered by the child or the time the parents need to take off of work to look after the sick child. Just says that many grow out of it.

I think your being exceptionally daft and narrow minded.

Ds has a Lycra suit on the NHS, his OT had to fight to get it accepted on the NHS and rightly so - it’s expensive and so the clinical need has to be proven. Clinicians can give their views but they need to listened to alongside the clinical guidance not instead of

Oh and theoretical risk (not actually observed) that it will increase respiratory infections and tonsils are not there to block pathogens.

Sometimes the clinicians most familiar with the patient dont get any say at all. That's the issue.

Mortality of 1 in 10000 for tonsillectomy, morbidity between 1.5-14%, mainly bleeding
www.mdedge.com/familymedicine/article/64070/pain/dont-overlook-complications-tonsillectomy

Lots of kids get a spell of having recurrent tonsillitis but will then grow out of it. That’s the whole point of those guidelines, to avoid operating on children who would have got better on their own.
Incidentally if you are so worried about lack of services for your patients don’t you think referring for investigation which are not necessarily indicated is a bit of a waste of scarce resources?
Tbh you come across as someone who just thinks they know better than anyone else so sod the guidelines

But while they (maybe) grow out of it, they experience pain, time off of school and their parents have to take time off of work. Then, if they dont grow out of it, the operation is worse overall as they are older.

It would be far better for GPs to be able to make individual decisions alongside an ENT specialist about who actually needs the surgery and who doesn't.

I think patient concern is enough of an indication for further investigation myself.

GeePee
There are many hair removal methods that are cheaper and also beneficial to your issue such as waxing, kits are extremely cheap on Amazon. It's what we advise patients with repeated sinuses to invest in.

While it seems like a reasonable idea to let clinicians prescribe the treatment they deemed most appropriate, without guidelines this would lead to quackery and people defrauding the NHS.

Healing crystal and reiki instead if antibiotics.
A trip for some sea air instead of a course of steroids for asthma patients.

If we start waxing men's cracks we do also have to start doing the monobrows of every self conscious teenage girl, because the GP said it would stop their anxiety and depression.

Sorry, but as a fellow doctor I shudder when I hear someone boast about being a “maverick”.

Perhaps read up on the narcissistic trap as it pertains to medicine. Our profession has no need for self-indulgence.

Regarding tonsilectomies,
It's interesting to study trends in ENT surgeries, many moons ago near on every child you met had gromits. When this became regulated suddenly huge swathes of children suddenly required their tonsils out and addenoids flushing. Almost as if ENTs suddenly had a bit of time on their hands and wanted something to do.

The guidelines are there and effective when followed in most cases, they prevent overzealous surgeons performing operations for generally routine childhood illness that can be cured with a course of antibiotics.

I think patient concern is enough of an indication for further investigation myself.
are you really a GP? Honestly I can’t imagine the cost of pursuing every concern. I know people who google and produce concerns constantly.

I’m surprised you’re getting such a hard time here OP. I absolutely agree with you. Unfortunately this sort of relies on all GPs being willing to think outside the box and stick up for their patients and IME many won’t do that.

There’s so much stuff that we are just so bad at. Thyroid issues being the perfect example. Too much reliance on TSH testing to the exclusion of the whole clinical picture and U.K. guidelines that mean huge number of people who would be treated in other countries just have to live with it until they exceed an arbitrary figure.

Also your stance on homebirth is wrong. There are specific guidelines regarding homebirth but at the bottom line a labouring mother cannot be refused the attendance of a midwife. The risks are explained and mitigated, an ambulance may be called. But at the thick of it, if a woman wants to give birth at home, she will be attended to. A midwife can try to everything within her power to get the patient to a hospital, either by trying to say they don't have a staff member available or by stating they need to go into hospital.

@everderose

Yes exactly. Women can birth where they want outside of guidelines and with the recommendation and support of a clinician because they are allowed more autonomy in that aspect of medicine.

Oh and waxing doesn't have the same reduction in reoccurance rates as laser hair removal.

@5zeds

Most people do not have misplaced concerns about their health. What can provoke health anxiety is constant dismissal of genuine complaints. If I can solve their issue in the surgery, people are generally happy not to go elsewhere.

This idea of everyone coming to the GP for total nonsense is completely misplaced. There is maybe 1 person a week who I think did not need an appointment and a bit of a waste of time.

The difference is a woman in labour will give birth . It's inevitable the baby is coming out if someone attends or doesn't. Therefore they are attended to mitigate risks.

Lasering a hairy crack isn't comparable.

Waxing does help reduction rates if kept up to. Maybe not as effectively as lasering but for most people they will find it helps. It's also incredibly cheap and most people can do themselves or with a bit of help from someone.

I understand how awful sinuses are, my eyes watered whenever I've packed one. They take an age to heal and are frankly really bloody embarrassing for the young men who seem so prone to them.

But lasering is expensive and compared to other things we don't fund, which can only be done by a medical professional and cost into thousands, it seems petty.

How would we ensure that this greater autonomy didn't lead to more 'mavericks' like Ian Paterson?

If it will come out anywhere, why dont we force them into hospitals? Other countries do under police escort if necessary.

@EverdeRose

Waxing doesn't have the same reduction rates according to RCTs

I mean reducing the reoccurance of the sinus

@Butterymuffin

Well he managed to do this under the current system so what does that tell you?

There are many hair removal methods that are cheaper and also beneficial to your issue such as waxing, kits are extremely cheap on Amazon. It's what we advise patients with repeated sinuses to invest in.

Waxing is a terrible thing to advise to people who are prone to ingrown hairs. I did it for many years on myself but am not prone to ingrown hairs or especially hirsute. Even so, it's painful, cannot be done on areas with rash, ingrown hairs already, and really not advisable for amateur users to perform on nether regions where the skin is thinner.

With the advent of home IPL machines they are miles better at overall hair reduction, FAR less painful and far more user friendly.

Can't believe patients are still being advised to wax when these machines are on the whole way cheaper than waxing over the long term.

Well he managed to do this under the current system so what does that tell you?

That there would be more cases like him with fewer restrictions and oversight?