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INSIDE HEALTH

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Programme 4.

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TX:听 11.02.14听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 ERIKA WRIGHT

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Porter

Coming up in today鈥檚听programme:听 Gut instinct听鈥� why听doctors should acknowledge and embrace听gut feelings.听That little voice in your head questioning the diagnosis might just be right.

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Glucosamine 鈥� a popular alternative remedy for painful joints but the latest guidance from NICE implies it鈥檚 a waste of time and money. So why has a supplement,听once prescribed听on the NHS, fallen so far out of听favour?

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Alcohol 鈥� we听look听at the latest thinking on the role of medication in helping problem drinkers and discover why it is never听a good idea to try and drown your sorrows.

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Clip

Probably people who start out being depressed may well be taking alcohol as a form of medication to try and improve their mood, which obviously it鈥檚 not going to do 鈥� it鈥檚 going to make it worse.听 Equally people who are alcohol dependent may well become depressed because of the chemical changes that the alcohol has in the brain.

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Porter

More about the relationship between alcohol and depression later. But first arthritis and new guidance this week from the National Institute for Health and Care Excellence on how to diagnose and treat osteoarthritis, a condition thought to affect joints like the hands, knees, hips and spines of at least eight million people in the UK.听 The guidance was expected somewhat controversially to advise against the routine use of regular paracetamol to ease pain and stiffness but there are reports of a last minute change of heart.听 Margaret McCartney is in our Glasgow studio. 听Margaret, why were NICE concerned about paracetamol in the first place?

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McCartney

Well there were two main problems.听 The first one was that NICE had felt that for many people using paracetamol for osteoarthritis pain was no more effective than placebo, so they had identified a group of patients who were using paracetamol with no additional benefit beyond that placebo.听 The second problem was they felt that some research had identified that paracetamol used high dose and in the long term had an increased risk of complications such as heart attacks, strokes and gastrointestinal bleeds.听 Now the problem with this research evidence was that it wasn鈥檛 very strong but NICE had initially felt that it was strong enough to urge caution for doctors who were recommending long term high dose paracetamol for patients.

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Porter

And I suppose this is a risk versus benefit, isn鈥檛 it, if the drug鈥檚 not working that well for a lot of people then you worry more about the side effects.

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McCartney

Absolutely, it鈥檚 all about the risk/benefit ratio.听 So if you鈥檙e taking something and you鈥檙e not getting any positive effect but you鈥檙e at risk of side effects, that鈥檚 one thing, but if you鈥檙e taking a drug and that鈥檚 actually having quite a good effect on you you might be quite willing to accept a small risk of complications because of that.听 But I think the problem for me has been that the research evidence that NICE had relied on to make this association between a risk of side effects and this long term high usage of paracetamol actually is not terribly strong.听 Additionally the problem is when you don鈥檛 recommend paracetamol well what are you going to recommend instead?听 How do we know that not using paracetamol regularly is better for us than the alternative which might be using anti-inflammatory drugs, which we know have a higher risk of gastrointestinal side effects or even using opiate based drugs, which obviously have many more side effects compared with paracetamol?听 So I think really what is the risk/benefit from not using paracetamol?听 That鈥檚 the question we鈥檝e still to answer.

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Porter

Margaret McCartney thank you very much.听

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What didn鈥檛 get a reprieve though in the new guidance was the supplement glucosamine 鈥� NICE does not believe there鈥檚 enough evidence to support the use of glucosamine in osteoarthritis, with or without the other popular ingredient chondroitin.

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So why do so many people take it? And why do some studies suggest it helps arthritis, while others don't? Questions I put to Professor John听Kirwan听, Consultant Rheumatologist at the Bristol Royal Infirmary.

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Kirwan

The situation with glucosamine is a bit of a confusing area and this is because glucosamine isn鈥檛 officially a medicine.听 Theoretically it鈥檚 a food, it鈥檚 called a nutraceutical, which is a food that鈥檚 thought to have some medicinal properties and it鈥檚 possible to extract it from cocks combs 鈥� the bits on the head of chickens 鈥� and you can extract it from shell fish and there鈥檚 various other places you can get it from.听 And so the way it鈥檚 licensed for use and the way it鈥檚 prescribed and the way people take it and the information that鈥檚 available isn鈥檛 the same as it would be if you had a routine medicine.听 For example you don鈥檛 have to prove things in the same way for glucosamine as you would have to do for a painkiller tablet and as long as you don鈥檛 actually tell lies about it you can say whatever you like.

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Porter

So you can make claims like it may help your joints and that鈥檚 not a medicinal claim per se 鈥� you鈥檙e not saying it鈥檚 treating arthritis?

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Kirwan

Well the word 鈥渕ay鈥� is the key here because that means it might not as well.听 In fact if you look on the web, for example, or look on adverts on buses to see what is said about glucosamine the adverts focus on the reports of individual people who鈥檝e tried it who say how good it was for them.听 And that鈥檚 a true statement, that鈥檚 what these people have said but there鈥檚 all sorts of reasons why people might get less pain from their arthritis if they take glucosamine, which has got nothing to do with the actual glucosamine.

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Porter

One of the things that I find confusing as a healthcare professional is you do see reports of trials into glucosamine and with osteoarthritis of the knee, for instance, I can remember a couple of those where they say that this seems to have an effect and then somewhere along the line you鈥檇 read a review that says it has no effect.

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Kirwan

Well there are a variety of reports but you know life is not black and white, so that when we do our clinical trials just because you鈥檝e done a clinical trial, even if you do it properly, it doesn鈥檛 automatically mean that you鈥檝e got the right answer from the trial, especially if you do small clinical trials with only a few people in 鈥� a dozen or two dozen people.听 It鈥檚 easy by chance to get some people who get a lot better during your trial and happening to be taking the medication or happen to have been taking the substance glucosamine.听 And then you get the results of the trial and it looks like it works.听 The trouble is you would do another trial with another dozen people in it and it would look like it didn鈥檛 work.听 And the problem with glucosamine is that the trials that look like it works get published in the medical literature and get quoted and the trials that look like it doesn鈥檛 work just get forgotten and never get published.听

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And there鈥檚 a way of recognising this, there鈥檚 a scientific way of recognising this, that we actually teach our medical students and I actually use the example of glucosamine to teach this way of recognising things and it鈥檚 called publication bias.听 And if you were a company making a new product that you thought might help people you could do lots and lots of small trials and some of them would say it鈥檚 helpful and some of them say it鈥檚 not helpful and you just publish the ones that say it鈥檚 helpful and then you could point to the literature, the reports in the scientific literature, and you could say look at this there are seven reports in the scientific literature that say it鈥檚 helpful.听 And if you take the average of them, which is what a review normally does, it takes the average of all the reports, the average says it works but that鈥檚 because you鈥檝e left out half of the information that says it doesn鈥檛 work and so there鈥檚 nothing to balance out the viewpoint.听 The way to get round that 鈥� there鈥檚 two ways to get round that, one is to make sure that all the results for all trials are always published and there is a campaign at the moment called 鈥淭he All Trials Campaign鈥�, which you might well have heard about, which is trying to make sure that happens and if that happens then when we do these amalgamated reviews of putting all the results together they鈥檒l be more accurate.听 The other way to do it is to do big trials because on big trials you don鈥檛 get this random variation, you get a much more correct picture.听 And there have been two very big trials done of glucosamine in osteoarthritis of the knee, one in the UK and one in America, and they both came to the same answer which was there鈥檚 no real benefit.

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Porter

And has that answered this conundrum for you, you鈥檙e quite happy now that we know that glucosamine doesn鈥檛 help arthritis?

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Kirwan

So there鈥檚 two things there, I鈥檓 quite happy that it doesn鈥檛 have a medical effect on the arthritis on the joints but there may be other reasons why glucosamine might be helpful for patients and we also talk to our medical students about these other reasons too.听 There鈥檚 an attitude that people take to their illnesses called self-efficacy, which means people who have high self-efficacy feel that there鈥檚 something they personally can do that will help their disease and make their pain less and make them more able to walk around etc.听 And there鈥檚 quite a lot of evidence in the psychology literature that if you have high self-efficacy you suffer less symptoms from whatever disease that you鈥檝e got and you鈥檙e able to do more things, whatever the disease is.听 Now to me when some patients who鈥檝e got say osteoarthritis of the knee or any other problem decide that it鈥檚 time for themselves to do something about it and they鈥檙e going to go out and try these tablets out, to me that is increasing their self-efficacy, they鈥檙e feeling that they鈥檙e taking charge of the situation and doing something about it.听 And I think that that sometimes makes some people feel better and have less pain and able to do more, it doesn鈥檛 have anything to do with the chemical effects of the glucosamine, it has to do with their state of mind and their approach to managing their own arthritis and their own pain.

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Porter

Is there a downside to taking glucosamine that you鈥檙e aware of?

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Kirwan

Well there are some downsides.听 I mean if you look in the British National Formulary it actually lists glucosamine in there and it says there are side effects and some people get nausea and vomiting and so on.听 But the real downside to me is it might make people miss out on some otherwise good treatments because they think they should be using this instead of ordinary treatments.听 The most important one is physiotherapy and exercise and so on, you can use painkillers and there are some additional treatments that you can use for osteoarthritis.听 What worries me is that I do occasionally see people who somehow feel the proven treatments are something they should be avoiding and they鈥檒l take glucosamine instead, I think that鈥檚 a bad thing.听 I mean you have to spend money on it as well, although you can get it quite cheaply on the internet but if people want to spend a little bit of their own money and try it out and if they feel personally that it鈥檚 helping them it鈥檚 probably not doing any harm.

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Porter

It鈥檚 quite interesting that when people look for something to help themselves they turn to a tablet like glucosamine or a capsule and they don鈥檛 look at, for instance, exercise 鈥� physiotherapy 鈥� strengthening the thigh muscles which can help in osteoarthritis of the knee.

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Kirwan

It certainly can help and those would be things that we鈥檇 advise people 鈥� and weight loss if you鈥檙e overweight and regular exercise and so on.听 Well you know different people expect different things from life and some people just are more tuned in to taking tablets and things and so they like to do that.听 I don鈥檛 advise people to take glucosamine and if my patients ask me about it I tell them what I鈥檝e been telling you and I鈥檒l let them decide what to do.

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Porter

Professor John听Kirwan, breaking the news as gently as he can.

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And if there is an issue, like glucosamine, that is confusing you then please do get in touch 鈥� you can e-mail us via insidehealth@bbc.co.uk.

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One听listener -听who wishes to remain anonymous听鈥� e-mailed to ask听why you hear so little about new drug based treatments for problem drinkers. Drugs like听nalmefene听and naltrexone听have made the headlines recently, but what sort of impact do they actually have clinically?

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I know just the people to ask.

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NICE has recently looked at the role of medicines in treating alcohol abuse and Colin听Drummond, Professor of Addiction Psychiatry at Kings College London, chaired the group behind the latest guidelines.听 And Anne听Lingford听Hughes is a consultant psychiatrist and Professor of Addiction Biology at Imperial College.

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Hughes

We know that from the clinical trials they are effective but we鈥檙e now starting to understand how they may affect brain mechanisms, how alcohol is affecting the brain and therefore how these drugs may interact with those mechanisms to help people stop drinking or stop the risk of relapse 鈥� so stop craving or other mechanisms like that.

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Porter

Is there a common pathway that these drugs are working on or do they have unique actions?

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Hughes

Each has their own particular target but we think a common theme is that they alter processes in the brain such as reward.听 There are others that possibly have an effect on impulsivity and it鈥檚 this type of mechanism that we鈥檙e just now starting to unravel.

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Porter

Colin, looking at the evidence for these drugs what sort of impact do they have, I mean is it pronounced?

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Drummond

Yes it鈥檚 certainly a significant effect on reducing people鈥檚 alcohol consumption, providing they鈥檙e taken as directed and on a regular basis.听 And also providing they鈥檙e prescribed in the context of a wider treatment plan with psychological interventions and social support.听 But it seems remarkably difficult to persuade doctors to prescribe in this condition, in other words it鈥檚 not very hard to get them to prescribe for depression.听 The data on prescribing that we have on drugs like acamprosate is that it is prescribed very rarely compared to what we know is the prevalence of the problem.听 And this isn鈥檛 just the UK, this is true in the United States and the National Institutes of Health in the US have been scratching their heads and trying to think how do we persuade doctors to embrace these drugs more.听 There鈥檚 a kind of general feeling, a sort of nihilistic feeling amongst some doctors that you just cannot do anything for this population.

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Porter

Why do you think that is?

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Drummond

I think it鈥檚 partly there鈥檚 a lack of training, I think also alcohol is competing with all the other things that doctors have to do in the course of what it is now seven minute interview, they鈥檙e being asked to look at smoking, diet, other lifestyle issues and鈥�

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Porter

Not asked to look at alcohol though specifically in most people, I mean we do in the over 40s but it鈥檚 interesting that it鈥檚 been left out of that sort of list of tick boxes.

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Drummond

Exactly and yet we have very effective interventions.

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Porter

It鈥檚 an oft abused clich茅 but it does have the ring of the Cinderella of the addiction world and I鈥檓 just intrigued as to how it鈥檚 got there, it鈥檚 just been left behind has it?

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Drummond

Well in a policy sense I think the excitement in government has been around drugs and drug misuse and what to do about that.

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Porter

And the war on smoking has been all consuming hasn鈥檛 it.

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Drummond

Absolutely and not just about helping people to quit but actually making tobacco less available.

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Porter

You must look at the protocols with envy from the alcohol.

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Drummond

I think we could learn a lot from the tobacco field to be honest.

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Hughes

So I鈥檓 aware of people who do contact us wanting medication but either their GP doesn鈥檛 know about it enough, which I think is perfectly understandable, as Colin鈥檚 already discussed about training etc., is a major issue, but I have had the situation where it鈥檚 been hard for me to start in specialist care, the GP may be willing but the approvals aren鈥檛 in place.

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Porter

Is there concern from some quarters of the medicalisation of this?

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Drummond

It sort of comes down to partly what you think the problem is, if you think the problem is a sort of lifestyle choice or a psychological issue then you鈥檙e probably not going to see much of a role for drugs.听 But I think Anne and I would probably see it as a much more complex picture.听 Alcohol is a drug itself, it鈥檚 having effects on the brain, that鈥檚 what鈥檚 producing the dependence and the drugs, although we don鈥檛 completely understand how they work, are probably reversing some of those effects.

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Porter

And these sorts of effects that the drugs are reversing are they the result of long term drinking or are they something that might have pre-existed that made the person more likely to be a problem drinker in the first place?

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Hughes

Probably both, we don鈥檛 understand that yet but certainly we鈥檝e got a large scanning programme on at the moment looking at reward mechanisms and impulsivity and sort of emotional stress and looking at how a drug like naltrexone might modulate those responses and we鈥檙e just starting to get the data out now.听 But certainly we know that naltrexone can change reward responding in the brain, it can change impulsivity activity in the brain, so we think it鈥檚 getting some of the core mechanisms.

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Porter

And it would dampen down the reward and make you less impulsive 鈥� that would be the aim which you would say 鈥� would suggest would be helping someone control their drinking?

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Hughes

Yes. I mean interestingly alcoholics have a blunted reward system to alcohol salient cues and that鈥檚 because we鈥檙e probably in a sense got tolerant to the cues, their natural 鈥� so-called natural pleasure/reward system isn鈥檛 working properly.听 Now that taps into depression, which has been mentioned a few times, that many people with alcohol problems are depressed.听 Well if alcohol has done that to your reward system then you won鈥檛 get the non-drug pleasures out of life.听 So one of the things naltrexone might do in this case is tend to normalise this function to help you respond to the non-drug pleasures but dampen the drug related pleasures down.听 And I think it鈥檚 understanding that because it is odd, in a sense, the most common drug probably prescribed to a person with alcohol problems is an anti-depressant, whereas the clinical trials are very clear that they don鈥檛 improve either depression unless you鈥檙e severely depressed nor alcohol consumption.

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Drummond

Another problem is that if you鈥檙e prescribing anti-depressants and treating depression in somebody with alcohol dependence you鈥檙e delaying treating the alcohol dependence, which is the thing that鈥檚 going to have change before the depression is going to improve.听 But the good 鈥� the positive news is that people that we see coming into treatment with both alcohol dependence and depression, and it鈥檚 very, very common, the studies have shown 60-70% of people coming in to treatment for alcohol dependence are depressed, but the vast majority of them the depression improves very quickly after they stop drinking but they may have been suffering from depression for years.

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Hughes

So what generally happens is that a patient may present with depression, they get prescribed an anti-depressant before the extent of their alcohol use has either been acknowledged by the individual themselves or picked up by a professional and the anti-depressant does not work, often they then re-present, they鈥檙e tried on a second anti-depressant and this was very common in my clinical practice 鈥� you see people on their second or third anti-depressant and they鈥檙e almost getting labelled as treatment resistant but in fact their alcohol misuse has not come to light.听 And we know very clearly from trials that in this situation the anti-depressant will not be doing anything to their alcohol consumption and will be having marginal if any effects on the depression.听 So the patient who says if you give me an anti-depressant I won鈥檛 be depressed anymore, it will make me feel better, then I won鈥檛 need to drink we can say that there is no evidence to support that.

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Porter

Treating the wrong problem.

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Hughes

Exactly, you have 鈥� whether or not you get treated for your depression you have to enter into treatment for your alcoholism.听 And that message has come up time and time again but unfortunately it is very hard and understandably hard when you have a depressed person in front of you who won鈥檛 go and seek help or even entertain the idea they may have a problem with alcohol, you can see why the clinical situation arises.

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Drummond

There鈥檚 a kind of overlap of the two conditions and probably people who start out being depressed may well be taking alcohol as a form of medication to try and improve their mood which obviously it鈥檚 not going to do, it鈥檚 going to make it worse.听 Equally people who are alcohol dependent may well become depressed because of the chemical changes that the alcohol has in the brain.

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Porter

But the simple message is that if you鈥檙e dealing with someone who has depression then it鈥檚 very important to ask them about their alcohol consumption.

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Drummond

Absolutely, they鈥檙e going to be a high risk group for alcohol problems.

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Porter

Professors Colin Drummond听and听Anne听Lingford Hughes.听And there is a link to the latest NICE guidance on alcohol 鈥� which includes a section on the role of medication 鈥� on our website.

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Now,听you know听that little voice in your head that questions if you鈥檝e locked the car听properly听or turned the iron off.听That uneasy feeling that you get when you think there is something that you should be doing, but you just can鈥檛 remember what it is?

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More often than not these听are groundless anxieties that听simply听reflect听that听many of us are born worriers, but sometimes that voice in your head -听that gut feeling听- warrants your attention.

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And听many听doctors, particularly GPs,听do听pay it attention when faced with a patient that doesn鈥檛 quite fit the description in the textbook 鈥� all may appear well on the surface but you are left with a nagging doubt that all is not quite as it seems.

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So are doctors right to heed their听gut instincts?听 Ann Van Den听Bruel听is a GP and听research fellow at the University of Oxford.

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Van Den Bruel

A lot of GPs especially they recognise this feeling that they get sometimes although not everybody admits or acknowledges that they sometimes act upon it, it鈥檚 seen as something mysterious or maybe you should not talk about it.听 But it is real and when you talk to GPs about it they鈥檙e really happy to be able to share that experience of having this gut feeling and using it sometimes in their medical decision making.听 So it is something real but it鈥檚 not always acknowledged as a valid or a useful tool.

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Porter

Well do we know if it鈥檚 useful?

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Van Den Bruel

Well we do because we鈥檝e been doing studies in, for example, serious infections in children, so that鈥檚 meningitis or pneumonia, and we have found that gut feeling is the most powerful predictor in general practice of a serious infection in a child.

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Porter

But how do you go about measuring the effect of something like gut feeling?

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Van Den Bruel

Well we asked doctors to record whether they felt something like gut feeling or an instinct that something was wrong in 4,000 children and then we compared those recordings with what ultimately happened to those children and we were able to calculate the diagnostic accuracy, if you want, of gut feeling.听 And we found that it is very, very accurate, it鈥檚 very useful.听 It鈥檚 not a hundred per cent right but the chance that something serious is going on is much higher when a doctor has a gut feeling.

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Porter

Well Margaret McCartney鈥檚 been listening in from our Glasgow studio.听 Margaret, I suspect that none of this will come as a surprise to you.

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McCartney

No and I think gut instinct is one of those real rich seams of general practice that kind of goes under explored and I think unacknowledged as well.听 When you talk to doctors over coffee one of the things that we鈥檙e always saying to each other is 鈥� just not quite sure about that lady or I鈥檓 just not quite sure about that hanging together.听 But I think there鈥檚 also a little bit of shame that goes along with it, I think sometimes it鈥檚 seen as being a bit unscientific 鈥� just having this gut instinct, this sort of feeling about someone and it鈥檚 a kind of slightly romantic idea that harks back to the old style videos of pictures of doctors just having a feeling about someone.听 For me it鈥檚 not unscientific at all, it鈥檚 actually highly scientific because what you鈥檙e doing is you鈥檙e saying actually out of all the people that I鈥檝e seen with similar symptoms you鈥檙e just a bit different from everyone else, it鈥檚 almost like recognising that this person just doesn鈥檛 quite fit the pattern but you鈥檙e not quite sure in what way they don鈥檛 fit in with that pattern.听 So what you鈥檙e doing is you鈥檙e opening up to saying well I鈥檓 unsure, I鈥檓 uncertain and the possibilities here are potentially something quite serious and I鈥檓 not going to just let that go.

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Porter

And this isn鈥檛 the only piece of evidence that suggests that it鈥檚 a powerful tool.

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McCartney

No and what I find really fascinating is when you go and ask doctors around the world, as some researchers have done, do you experience a similar kind of phenomena, all doctors will say that they do.听 Some people will describe it as feeling something in their stomach, something just not quite right, other doctors will say that they feel it in their bones that something鈥檚 just not right and it鈥檚 just this idea that you get something that jars, something that just doesn鈥檛 quite fit properly together and you have a sense that you鈥檙e not actually very certain about what鈥檚 going on here at all.

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Van Den Bruel

In general practice we have to deal with a lot of uncertainty, we don鈥檛 have all the tests and all the technology the hospital doctors do have and so we鈥檙e used to dealing with uncertainty and we鈥檙e used to not having that much at our disposal to make our decisions.听 So gut feeling for us is like our safety net, when we feel I鈥檓 not really happy about this then we may want to ask a second opinion or we may want to schedule another appointment or we may want to give the parents very detailed information on when to come back 鈥� that鈥檚 how we want to deal with that uncertainty that is left at the end of the consultation.

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Porter

It鈥檚 interesting in this day and age because we鈥檙e very protocol driven, so examining a sick child, for instance, we look for pulse rate, the colour of their skin, tone, lots of other things that are laid out 鈥� there鈥檚 this little tick box that you can go through to evaluate whether a child is seriously ill or not.听 And what you鈥檙e saying is that the gut feeling鈥檚 not on that but we should be listening to our gut feeling.

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Van Den Bruel

Yes, well I think first of all doctors should be doing it systematically and they should look at all the things that you just mentioned 鈥� colour, temperature, breathing rate 鈥� so that鈥檚 what they should do because they鈥檙e very, very useful in detecting serious illness.听 But on top of that they should also listen to their gut feeling 鈥� so when everything seems to be alright, when the breathing rate is normal and the temperature is not that abnormal, in addition to all these things when you have a gut feeling then you might pick up some children with a serious infection over and above what you have done in your tick box.

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Porter

Another problem with our sort of modern healthcare system is that when you鈥檙e referring patients in for specialist treatment or for emergency treatment sometimes you are expected to jump through certain diagnostic hoops and you can鈥檛 really tick a box for gut instinct can you?

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Van Den Bruel

No, I think healthcare should allow for flexibility in referrals, so we need the systematic referral process but we also need some flexibility to circumvent the systematic referral process where doctors are unhappy with presentation, doctors feel uneasy about this patient and they should be able to refer that patient despite a systematic examination being normal.

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Porter

And what your research shows is that we shouldn鈥檛 be embarrassed about it, it鈥檚 a useful thing to have.

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Van Den Bruel

Yes.

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McCartney

I suppose this is what really frustrates me about the way that medicine is going.听 When I want to refer someone to hospital very often I鈥檝e got a form to fill in and very often that form has lots of boxes that I have to tick on it and for example if I鈥檓 concerned that someone has a serious underlying bowel condition there is lots of boxes to tick 鈥� have you had blood in your stools, have you had diarrhoea, have you had weight loss 鈥� those kind of things are what we鈥檇 call red flag signals, something that鈥檚 quite definitively abnormal, something that鈥檚 not right.听 But in actual fact people don鈥檛 always come in like that, they鈥檒l say well I鈥檓 just not quite sure, things are a little bit different normal but not terribly abnormal.听 And actually when you look through the data about doctors that refer patients outside strict guidelines actually when doctors are concerned very often there鈥檚 a good reason for that and the serious diagnoses that are uncovered through referrals with guidelines are actually relatively fairly high.听 So I think we really have to listen to this gut instinct and really enable doctors to work with it rather than trying to work against it all the time because I think it means something and I think it鈥檚 something very useful.

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Porter

Are you implying that protocols are designed to guide us to improve our diagnostic skills on the one hand may actually be blunting this gut instinct on the other?

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McCartney

I absolutely think so.听 Often guidelines are quite useful, they can help symptom sort, they can help out work out probabilities but they will not tell you about everyone and I think that doctors when they feel that something isn鈥檛 right we should be allowed to feel that something isn鈥檛 right and we should be able to refer people for further investigations when we鈥檙e concerned about them anyway.听 And I think sometimes with guidelines and being judged according to how well we follow guidelines is not really a way to embrace these kind of intuitions and use that to get our diagnostic skills better.

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Porter

Margaret McCartney and Ann Van Den听Bruel reminding us to listen听to the听little voices听in our heads. And you will find a link to Ann鈥檚 research on the Inside Health page of the Radio 4 website.听 听

Next week I will be learning more about the impact of air pollution on our health, and how cyclists, joggers and pedestrians can reduce their exposure.听Join me then to find out more.

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ENDS听