This is the text of an article I wrote for a medical journal some 25 years ago. At that time we had CT scanning only, and the facilities were few, tending to have long waiting lists unless the request was urgent. Nowadays NHS hospital policy would dictate an MRI headscan for every case of headache referred to the clinic.
"Errors happen when doctors use their clinical judgement." "A normal headscan gives final reassurance and is therapeutic." Such arguments are frequently heard.
So who is to say that excellence was or was not achieved in the management of a specified case? The practitioner? His peers? The patient? A duly appointed committee of all interested parties?
Maybe. But the physician in me still questions the quality of management which devalues clinical judgement, and depends on routine, expensive investigation.
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What is medical excellence? Medical competence or incompetence may be recognisable, but these attributes can be judged on the grounds of safety and convention. Excellence is a judgment of quality. Its definition must be subjective. Like beauty it lies in the eye of the beholder. Medical practice is a creative activity: its assessment must have something in common with art appreciation.
So who is to say that excellence was or was not achieved in the management of a specified case? The practitioner? His peers? The patient? A duly appointed committee of all interested parties?
The practitioner is best placed to know, but cannot judge objectively. His peers will very likely hold different opinions or values concerning some aspects of the case. The patient's views must be important, but we can each recall occasions when bungled or erroneous management produced embarrassing praise and thanks. Surely not a committee, earnestly seeking a diplomatic average view.
Perhaps medical excellence can be judged only by the professional conscience of each doctor for himself, a conclusion which many may find uncomfortable, but which may be unavoidable.
These thoughts and more have run through my head following a recent case.
My heart sank when I read the courteous and succinct referral letter from a general practitioner whom I know well and respect. A 17 years' old girl with intractable headaches. It was the last case on the list, the end of a long clinic. I was tired and running late. Sister had glanced at her watch.
Miss C entered and sat down. Quiet, mature, in school uniform with a prefect's badge, but uneasy, even a little hostile. Both parents came in too: well to do and worried. Father did most of the talking, prompted by mother. Their daughter sat and fidgeted, answering direct questions in monosyllables. The history was familiar.
All was well until three months ago. Her school reports were always good, and she was in for four papers at "A" level next year. Her teachers had spoken of a sixth form career leading to university - Oxford, perhaps, even medical school.
These thoughts and more have run through my head following a recent case.
My heart sank when I read the courteous and succinct referral letter from a general practitioner whom I know well and respect. A 17 years' old girl with intractable headaches. It was the last case on the list, the end of a long clinic. I was tired and running late. Sister had glanced at her watch.
Miss C entered and sat down. Quiet, mature, in school uniform with a prefect's badge, but uneasy, even a little hostile. Both parents came in too: well to do and worried. Father did most of the talking, prompted by mother. Their daughter sat and fidgeted, answering direct questions in monosyllables. The history was familiar.
All was well until three months ago. Her school reports were always good, and she was in for four papers at "A" level next year. Her teachers had spoken of a sixth form career leading to university - Oxford, perhaps, even medical school.
But then the headaches started, and now all their hopes were in jeopardy. Each day she came home listless and pale, complaining of pain behind her eyes and round her head like a tight band. She would say that her head was going to burst. She was irritable and emotional. Sometimes she had sat with her head in her hands and wept because of the pain. Often she would go to her room and spend all evening just lying on her bed with the door shut. Homework was not being done.
Headache did not disturb sleep, and was little problem in the mornings, but waking and getting up were difficult. She had been late in school on several occasions, an event unknown before. She had lost all interest in other activities, and never played the piano now.
When Father began to describe his daughter's dysmenorrhoea I retreated to the examination cubicle.
There were no physical signs; indeed, she seemed to be in excellent health. She was no more forthcoming about her troubles when her parents were absent.
The diagnosis was clear: tension headache syndrome. She needed explanation, discussion of precipitating factors (if admitted), and reassurance. But it was going to be difficult. Heads are mysterious and important. Pain must mean something is wrong. Brain tumours can cause headaches, and rarely might present like this. Surely a brain scan should be done?
At such times I become aware of an angel whispering into my right ear, and a snake into my left.
There were no physical signs; indeed, she seemed to be in excellent health. She was no more forthcoming about her troubles when her parents were absent.
The diagnosis was clear: tension headache syndrome. She needed explanation, discussion of precipitating factors (if admitted), and reassurance. But it was going to be difficult. Heads are mysterious and important. Pain must mean something is wrong. Brain tumours can cause headaches, and rarely might present like this. Surely a brain scan should be done?
At such times I become aware of an angel whispering into my right ear, and a snake into my left.
The angel says that I am reasonably sure of the diagnosis. The roots of the trouble are in the parents as much as in the girl. To treat their anxieties and ambitions by ordering unnecessary X-ray examinations on their daughter doesn't make much sense. Young women should be protected from radiation. Only yesterday there had been that letter from the radiologist pointing out how the demand for brain scans had increased, and how small a fraction of all those done showed abnormalities.
The snake is a realist. Nothing that l say will finally reassure the parents. I admit l cannot be absolute about the diagnosis. The general practitioner has suggested that a scan might be necessary and the parents are expecting it. If I do not do it then no doubt there will be another referral to someone who will, probably that old so and so in the next town who will see them privately and discreetly imply that I am careless in such matters. What if new signs appear and there is a tumour? I might be sued.
It had been a long day. I shied from the hassle. I listened to the snake.
The scan was normal. I heard that she did well in the examinations, and that the headaches are much less troublesome, but I have not seen her since.
Her parents and their general practitioner were pleased and satisfied. I cannot speak for the patient.
l am not. I know that I failed to achieve excellence in this case. Worse, l suspect that I shall do the same again next time. It is always easier in medical practice to do something than it is to explain convincingly why it is unnecessary.
Perhaps medical excellence is impracticable.
The snake is a realist. Nothing that l say will finally reassure the parents. I admit l cannot be absolute about the diagnosis. The general practitioner has suggested that a scan might be necessary and the parents are expecting it. If I do not do it then no doubt there will be another referral to someone who will, probably that old so and so in the next town who will see them privately and discreetly imply that I am careless in such matters. What if new signs appear and there is a tumour? I might be sued.
It had been a long day. I shied from the hassle. I listened to the snake.
The scan was normal. I heard that she did well in the examinations, and that the headaches are much less troublesome, but I have not seen her since.
Her parents and their general practitioner were pleased and satisfied. I cannot speak for the patient.
l am not. I know that I failed to achieve excellence in this case. Worse, l suspect that I shall do the same again next time. It is always easier in medical practice to do something than it is to explain convincingly why it is unnecessary.
Perhaps medical excellence is impracticable.
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