Protocol driven medicine versus individual medical practices.

Mr Paterson worked in Solihul Hospital as a breast surgeon.  There have been a number of stories emerging about his practice.  Basically, he performed cleavage sparing mastectomies which resulted in a lot of breast tissue being left after a mastectomy had been performed.  Thereafter, a number of women  experienced recurrence of their breast cancer.  The question is whether that happened as a result of their inadequate surgery or whether the behaviour of the cancer determined the outcome.

I trained as a doctor in the UK and have worked in South Africa for the last 20 years. I have thought about the pros and cons of a protocol driven system on many occasions.  The NHS is an example of a protocol driven system.  There are clear guidelines set out for all health practitioners and they exist for almost all conditions.  In South Africa, outside the teaching hospitals, there are few guidelines although the health funders do apply some.  There are advantages and disadvantages in either system.

Protocols can be cumbersome and can result in many unnecessary investigations being performed.  They don't allow common sense to be applied.  They don't allow for the Art of Medicine.  My father was treated in Solihul Hospital and the seriousness of his condition (24 hours before he died) was not appreciated as the "score" being used did not reflect his illness.  No health professional looked at him and saw a sick man needing urgent intervention.  They saw a chart.

A system allowing individual freedom is equally wasteful.  Doctors who are not experts in their fields may treat conditions sub-optimally.  Patients get treated with unproven management.  Multidisciplinary approaches to treatment are not mandatory resulting in individual non-evidence based medicine being practised.  

However, although there are some individuals who do not benefit from protocols, the majority do.  Protocols save patients from our ignorance and arrogance.

I am not sure whether we will ever find out why Mr Paterson was able to treat women with unconventional surgery for so long and why no one in his team drew attention to the problem earlier.

Do you have any thoughts on protocols?

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