In their personal statements, medical school candidates often wax lyrical about embarking on a journey of lifelong learning in the ever changing worlds of science and medicine. These days I have to admit that my journal reading is scant, and the blessed internet provides most of the information that keeps me abreast of change. It answers many of the questions that arise in daily practice—the known unknowns—and can do this in real time, often within the consultation. Alongside this—and revealing the unknown unknowns—I attend an annual update course.
At these courses the lecturers have five hours to try to cram in the most significant changes to the National Institute for Health and Care Excellence (NICE) guidelines that are relevant to GPs. Pre-covid, attending this course was always an enjoyable event, doubling as an opportunity to catch up with local colleagues; unfortunately, I had to attend the latest iteration remotely. There are good “green” reasons for remote learning, as well as reducing the risk of covid transmission, but it comes with significant disadvantages, not least the difficulty I have staying focused on my laptop for five hours. But the biggest loss for me is that of the opportunity to benchmark.
Sometimes, when the latest recommendations are presented, I find myself nodding along and feeling content that my practice is roughly in line with the guidelines. Quite often, however, I’m aware that my usual way of working is very different from the “gold standard” being presented. When this happens, what I really need to know is whether I’m out of step with my peers or whether it’s the guidelines that are unrealistic. Listening to a presentation in a shared auditorium, you rapidly get a sense of whether the information is new or surprising to most of the group and whether there’s a general feeling of acceptance or dissent.
This year the latest guidelines for treating depression were presented.1 These included the menu of modalities of treatment we should be offering: 11 different options for milder depression and 10 for more severe depression. I think we were probably all muttering “in your dreams” under our breath but, attending remotely, I couldn’t tell. The suggestions about what should be covered in each consultation seemed predicated on a very much longer meeting than the average GP appointment and included the recommendation that all patients who start medication for depression should be given personalised written information fully explaining the harms, benefits, and risk of withdrawal effects.
I’d be really interested to know if some practices feel able to offer care as specified in these guidelines. Clearly, they’re aspirational and directed partly at commissioners, given that they suggest a range of psychotherapeutic treatments that aren’t widely available—but they reveal a yawning gap between the ideal as imagined by NICE and the reality in the land of primary care.
I wish I’d been sitting in a room with colleagues and able to find out whether I was alone in my response. As it is, I’m not sure if—or how—I’ll alter my practice.