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We were all whole heartedly behind Adrian Dixon when he prepared the "little red book" of guidelines for the Royal College of Radiologists (RCR). Short, pithy, succinct: they briefly explained which investigation would help for a particular pathology. They were unashamedly aimed at non-radiological junior doctors. Thus a casualty officer could consult his red book and come up with a sensible request for radiological assistance. So successful was this idea that 100 000 copies of the 4th edition were sold by the RCR. I fully supported the initiative and I believe that it has improved patient care.
So far so good. But the scene changes.
I first noticed a shift in the use of guidelines when a large private hospital group sent round a notice that they were, from now on, keeping strictly to the RCR Red Book and that no pre-operative chest X-ray examinations would be carried out unless clinically indicated as specified in the book. All well and good, you might say; you cannot have one set of rules for the NHS and another for private medicine. But these were not supposed to be rules; they were guidelines for junior doctors, not directives for senior consultant radiologists!
The first reason for the guideline that one should not perform pre-operative chest radiography is the low clinical yield and thus poor cost efficiency. If there is no clinical indication for the pre-operative chest X-ray examination management is changed in only 1 in 1000 cases. Second, there is the radiation hazard from the examination, which has been assessed as approximately one in a million chance of inducing a cancer. But if the radiation hazard is so very, very low, perhaps a relatively low yield is acceptable. After all, 1 in 1000 would be considered a high yield compared with some screening programmes. If the patient is paying for the examination it can be argued that they want the best possible treatment and that the cost is irrelevant. Conversely, if the insurers are adhering to guidelines they will only pay up when the criteria are met; the insurers will turn guidelines into directives. Thou shalt not take pre-operative chest radiographs!
That very day as I read the directive in the private hospital and pondered upon the above dilemma, I picked up the first film on the pile. It was a pre-operative chest X-ray examination that had not been justified on the Red Book clinical grounds. It showed a moderate sized carcinoma of the bronchus, which would probably otherwise not have been diagnosed until much later in the clinical history. Careful re-examination of the patient's history, signs and symptoms might well have elicited indications for radiography in accordance with the Red Book. But the fact remains that the clinicians had not noted such a history. Who can deny that there are times when the clinical examination is not what it should be and that the clinical signs may be missed or the relevant question may not be asked? When the clinical examination is less than optimal, the yield from the pre-operative chest radiograph will be concomitantly higher.
It can be argued that the operation was irrelevant in this case and I might as well make a case for screening the population for carcinoma of the bronchus. Well, some people are making such a case using spiral or multislice CT, but I do not wish to pursue that line of reasoning. The pathology I found could have been different. Even in a young person a hiatus hernia, a common enough finding, may have considerably influenced management under anaesthesia. I have previously seen a case where achalasia was missed until the inevitable post-operative pneumonia followed reflux whilst under general anaesthesia.
The government gets in on the act with the National Institute of Clinical Excellence (NICE). The decree goes out that there will be guidelines and standards for the whole of medicine and that they must all be "evidence based". It is imperative that the fellows of the RCR should search the literature worldwide, and comb the Internet and Medline. The mountains of paperwork and the sweated brows go unpaid by government and yet the task is not complete. Indeed, if it was easy to set guidelines why should so many textbooks exists? How can any set of guidelines, however complex, compete with the plethora of journals and books that we seen in any medical library? Do not underestimate the work involved in trying to make guidelines "scientific". The RCR's chosen experts are heroically battling against a task of truly Herculean proportion.
It is sad to think that much of it could be futile since so few patients precisely meet the criteria... medicine is not a linear subject. Because of the chaotic non-linear nature of disease and its ramifications, guidelines are only a starting point. The art of medicine is required as well as the science. This cannot be distilled into simple guidelines and their transmogrification into standards and decrees would be most worrying. "Don't worry," I am told by RCR luminaries, "It won't happen. These will remain guidelines not directives." On this matter I have taken legal advice. A senior professor of medical law told me that non-adherence to guidelines would make one's action indefensible if something went wrong. So much for not becoming directives.
At best guidelines should be used to help direct and educate the less knowledgeable. At worst they are rods for our own backs. Good luck to the RCR in their production of the next issue, but let us see it hedged with circumspection. A comment such as "these guidelines are to assist in choosing investigations not in preventing them" and "Use as a directive is an abuse" might help if included on every page but I worry that this warning will not be heeded.
We may feel satisfied that we have been able to set guidelines and standards whilst the less ruly nations of southern Europe refuse to do so. But note that our health service is not the envy of the rest of the world and that our lemming-like rush to medical rationing has not served to improve health care but rather to worsen it. Could it be that many of the other nations have got it right and that the market economy rather than institutionalized medicine results in better health care?
Guidelines equal common sense. Directives equal rationing.
Yours etc.,
Department of Clinical Radiology, Bristol Royal Infirmary, Bristol B5Z 8HW, UK
Received for publication October 10, 2001. Accepted for publication January 21, 2002.
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  G Needham Guidelines not directives Br. J. Radiol., June 1, 2002; 75(894): 565 - 565. [Full Text] [PDF]
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