Filler

When guidelines fail

She was a 78 year old widow who lived in sheltered accommodation and, despite being partially sighted because of advancing glaucoma, was still able to get about with her white cane. She rarely visited our surgery, and when she did it was for a flu jab or regarding moderate generalised osteoarthritis. This morning, however, she limped into my consulting room apologetically and said, "The heel of my right foot is hurting, doctor. I'm finding it difficult to walk to the shops. My eyesight doesn't help either."

I set out to examine her foot. There was nothing grossly abnormal. It was well perfused, no swellings, and no evidence of any trauma. Deep palpation over the calcaneum produced tenderness. "Bingo," I thought, "plantar fasciitis, with or without calcaneal spur." I reached for an x ray form when I suddenly remembered the fate of the previous x ray form I had sent for an almost identical situation. A consultant radiologist from one of our teaching hospitals had politely returned my request form with a booklet containing guidelines from the Royal College of Radiologists. This had stated that routine radiography of the heel for calcaneal spur is of no value and not recommended. I didn't want my patient to travel all the way to the radiology department only to be sent back with another booklet of guidelines. I reassured her that this was a self limiting condition, prescribed some local rubefacient, and told her to wear a heel pad and to come back if there was no improvement.

Two weeks later, she asked for a home visit as the pain was no better. I visited her after the morning surgery rather grudginglya request for a home visit for such a minor condition? Examination did not reveal anything new, and I discussed the option of a local corticosteroid injection. She gladly accepted, and I arranged for her to visit the surgery in two days time and included her in my minor surgery list.

A carer brought her in, and her limp was more pronounced. I carried out the procedure and reassured her that she would soon improve.

The following week an irate son in law, who I had never met, telephoned the surgery asking that a doctor visit straight away as his mother in law was no better and in a lot of pain. The receptionist told him that the doctors were in the middle of a busy surgery and would visit around midday. An hour later he rang again to say that he was not prepared to wait and was taking his mother in law to the casualty department.

Ten days later I received a call from the hospital. My patient was to be discharged to her daughter's home address for terminal care. Widespread metastasis, including involvement of her right calcaneum, had been diagnosed, and no attempt was made to identify the primary. Completely shocked, I replaced the telephone receiver. It took several minutes to compose myself and continue the rest of the surgery. She rapidly deteriorated and died a few days later.

I have never heard of secondary deposits in the calcaneum. Would x ray examination have altered her prognosis? Most certainly not, but it would have spared her a painful injection. Pain management and other aspects of care would have been different.

This made me think about guidelines, of which there are so many. When it comes to an individual patient, you have to rely on your clinical sense and skills and not fall prey to generalised guidelines and pathways.

The question that I still cannot answer is how do I persuade a colleague in another specialty, who perhaps has not seen the patient, to overlook guidelines set out by his or her royal college and perform a simple investigation?

John Godfrey, general practitioner. 

Liverpool

We welcome articles of up to 600 words on topics such as A memorable patient, A paper that changed my practice, My most unfortunate mistake, or any other piece conveying instruction, pathos, or humour. If possible the article should be supplied on a disk. Permission is needed from the patient or a relative if an identifiable patient is referred to. We also welcome contributions for "Endpieces," consisting of quotations of up to 80 words (but most are considerably shorter) from any source, ancient or modern, which have appealed to the reader.