I can understand NICE's laudable intentions in providing evidence based guidance to the medical profession. I can also understand why such guidance is sometimes interpreted as being didactic by a profession that is increasingly anxious not to make mistakes since such errors may have profound life-threatening consequences. I can therefore also understand when guidance by NICE, particularly when publicised in the daily press, can appear to be a set of rules by which doctors must abide. And sadly I think that that is also the perception that our patients have. But the problem that we have as GPs is that we deal with individuals not populations.
Sadly we are seeing the demise of a model of family practice that has sustained the NHS over the past six decades. Under that model a GP had a long-term relationship with his or her patient. There was a broad understanding of the patient's medical and social history. There was continuity of care. Most of all there was trust between the two parties. Partly through the combination of a lack of full-time GPs and an increasing workload, that relationship is fast disappearing. Doctors regret but accept that fact and try to do their best in these changing circumstances.
In publishing its 'milestone' Guidance (NG23) on Menopause; Diagnosis and Management, as well as previous populist documents on common patient presentations to their GP, NICE basically only confirms what the great majority of doctors already do. But the public can only see this as some form of censure of the profession because of the tenor of the wording in the summary and which was widely reported. They therefore interpret it as doctors being, at best, ignorant or uninformed or, at worst, obstructive and this only leads to a further erosion of trust in their GP.
I do not dispute that some women were put off taking HRT because of advice from their doctor. However they were equally scared off by the widely publicised, 'gold-standard' research of a decade ago that they read in the press at the same time as their GP. To the layman and woman, ANY risk of cancer is naturally worrying and thus any INCREASED risk is of huge concern particularly in a common cancer, such as breast, where nearly everyone knows of someone who has had it.
Even doctors find the statistical nuances of relative and absolute risk difficult to understand so how can we expect our patients to assimilate the details when explained to them. Many look askance when we try to do so. Many will say; 'well you're the doctor-what do you think?' And what do we actually 'think' when we, as a scientific discipline, flip-flop between extremes with every new piece of research that emanates from academia.
It may sound condescending but surely the message was simpler and far more reassuring for the menopausal woman when her GP would say;
"I would have no hesitation in prescribing HRT for myself (or my wife)."
A milestone is defined as a significant stage or event in the development of something. NG23 is not a milestone document but another millstone around the neck of a profession that is trying to maintain the trust that patients have in it..
NICE needs to choose its words carefully. A 'sound bite' can often bite you back.