Dr Phil Hammond

There are hundreds of medical guidelines to ensure every doctor thinks, acts and diagnoses the same way. They rarely work

So, what's going down in the British Medical Journal?

Oh, nothing that concerns you.

Why not?

Because it seldom relates to real life. Think of a medical question you really want to ask, and I bet you won't find the answer in the BMJ.

OK, here's one. Do GPs act consistently when they meet the same patient twice?

Ah...

Ah what?

Well, there has been something vaguely along those lines in the BMJ recently.

Could you be more specific?

On 19 April, there was a paper spookily entitled "Do GPs act consistently when they meet the same patient twice?" But the work was done in Norway so it might not be relevant to us.

Which part of Norway?

Trondheim.

But that's where I live. God, isn't that amazing?

Yes, isn't it? So what interests you about medical consistency?

Well, I'm a 70-year-old woman and so is my identical twin.

Well, she would be, wouldn't she?

Yes, but we also have the same angina.

Are you paying tribute to Benny Hill or do you suffer identical coronary artery insufficiency?

The latter. Anyway, for a long time we have patronised different doctors and have been amazed at how inconsistent they were when presented with identical patients with identical symptoms. One spends ages dissecting the nature of the pain; another prefers to talk about our cousin Lars, who is in secure accommodation. One GP stripped my sister from nipples to knees for an examination; another tried to listen to my heart while I was wearing a whale-skin coat by forcing his stethoscope through the second and third buttons. Often, we leave through different doors with different diagnoses and different prescriptions. I thought medicine was a science, so why are we treated so non-identically?

Good question. Doctors like to attribute these glaring differences in performance to "the art of medicine" but often it occurs at the expense of the science. It's long been known that if you ask 20 cardiologists to listen to the same heart murmur, they give you 20 different diagnoses.

Why?

It could be due to anything from the length of the stethoscope to the amount of wax in the doctor's ears. To improve diagnostic accuracy, we now have fancy machines for heart tracings and echo-cardiograms. Used correctly, these can produce identical pictures.

For the doctors to interpret differently?

Correct.

But surely there are scientific guidelines to make sure doctors all think and do the same thing?

Oh yes, there are hundreds of these but doctors differ in their ability to recall which drawer they put them in, so either you can't find any or you end up treating angina with the irritable bowel guidelines. Remember - guidelines don't cover everything. Science won't tell you whether it's right or wrong for a doctor to ask after your cousin Lars.

Well, I think it's very thoughtful.

Good.

Yes. So good that Else and I decided to go to see this identical doctor with our identical problems.

And what did you find?

He treated us differently.

Oh dear.

On a Monday morning, Friday afternoon or after a night on call, he will never listen to our chests, explain his treatment or ask after Lars. On a Tuesday, he will take our blood pressure spontaneously and on Wednesday, we have to ask for it.

What about Thursday?

On Thursday, he makes us tea and shows us pictures of his children.

Fascinating. I sent two elderly female "standardised" patients (actors pretending to have angina in the same way) to 23 Trondheim GPs and found exactly that. The same doctor does different things to identical patients on different occasions.

I could have told you that.

You did.

And it's not very reassuring.

No, but at least it's not boringn