Tick Box Medicine

Dr No’s mother, a fit 80-something year old, recently attended an ophthalmology clinic, on the advice of her optician, and was told – out of the blue, by a nurse – she hadn’t even seen a doctor – that a bed had been arranged for her to come in two days later to have her cataract removed. The nurse was most put out when Dr No’s mother – who knows her mind very well – said she had no intention of coming in for an operation she neither knew about, nor did she need. Yes, she does wear reading glasses – but otherwise her eyesight is fine.

Last month, the ‘parent/carer’ of Cian Attwood received a letter from an NHS ‘systems manager’ warning that Cian was ‘very overweight – doctors call this clinically obese’, and could grow up with ‘dangerous amounts of fat’ in his body, before adding gleefully – presumably to ram the point home in case the ‘parent/carer’ had failed to appreciate the danger Cian was in – that he was at risk of cancer, diabetes and heart disease, and that ‘some of these can begin in childhood’. Cian does indeed have a high BMI – but he is not in the least bit obese.

These are but two examples of tick-box medicine, that growing parallel clinical world in which pseudo-doctors make pseudo-diagnoses and prescribe all too real treatments based not on clinical reason, but on protocol. The trouble is, the human body doesn’t ‘do’ protocol. People vary, but protocols don’t – which is why they come unstuck.

As a medical student, Dr No was taught to treat people not diagnoses. The person in bed six was not ‘the breast cancer’, but Mrs Jones, whose cancer affected her in her own unique way. In the same vein, he was taught never to consider a test result in isolation; instead, a test was always interpreted as part of the broader clinical picture. A BMI that might suggest obesity in one patient might just as well reflect high muscle bulk in another. It is only by considering the patient in the round, so to speak, that the true picture will emerge.

Doctors, who from their first day on the wards are taught the art of diagnosis, do this naturally. They expect to see the patient, and interpret in context. If Cian is evidently slim, then he is not obese, whatever the BMI says. Systems managers, and the other myriad lackeys who work in today’s NHS, interpret by protocol. If the BMI says obese, then the patient is obese.

Doctors, of course, do not come cheap, partly because they have spent many long years learning how to think, such that their reasoning is soft-wired; and they can handle the exception, because the protocol is only loosely embedded in their head. Systems managers, armed as they are with their tick boxes and their protocols, are hard-wired, and will brook no exception. They may be cheaper in the short term, but by the bigger picture, they will turn out – not always, by any means, but too often for comfort – to be an expensive mistake.