Mind the gap.|
James Lind discovered, in an early, small-scale randomized controlled trial, that citrus fruit halted the progress of scurvy. Many decades passed, however, before the incontrovertible evidence of the antiscorbutic effect of vitamin C became incorporated into everyday practice, and naval ratings were given fruit.
Many commentators have described the gap between evidence and practice, the delay in the implementation of research findings and the disparity between evidence-based or consensus guidelines and clinical reality. This is as true in gastroenterology as it is in other branches of medicine, but may not always be a bad thing.
Endoscopic screening for lower bowel cancer proceeds apace in the USA, in the absence of reliable evidence of efficacy, whilst in the UK the wait for definitive evidence seems interminable. If the current UK trial of one-off flexible sigmoidoscopy demonstrates a benefit that threatens to change health policy, you can be pretty sure that policy makers will find a way of stalling, probably by suggesting a trial of a molecular marker, which might turn out to be cheaper. Nobody really knows what to do with Barrett's esophagus, but a DDW workshop has drawn up further guidelines on surveillance at the same time as it recognized that the scientific basis for doing so is equivocal.
Barrett's esophagus is an example of another kind of gap - one that exists between specialist and generalist practice. Many of my colleagues, in primary care and in hospital medicine, aren't too sure even what Barrett's esophagus is, yet in tertiary centers around the world a Barrett's industry hums away. How often and how should we screen? What shall we do when we find something nasty? More questions, more air miles.
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Many general practitioners are hazy about the Manning criteria and certainly couldn't list the Rome II criteria, but make a pretty good fist of diagnosing and managing irritable bowel syndrome. Whether or not they have visited Maastricht, they are unlikely to be impressed by some of the more exotic recommendations of the most recent statement on Helicobacter pylori eradication, particularly in patients in whom long-term NSAID therapy is contemplated, and those in whom long-term PPI treatment may be indicated.
Perhaps these distinctions between primary and secondary care are most stark in the UK, where the origins of the NHS guaranteed a sharp separation between general practice and hospital medicine. Whilst having some advantages - a benign gatekeeping role, value for money and personal continuity of care are examples - this medical tribalism is ultimately counter-productive.
For many years the Primary Care Society for Gastroenterology in the UK and, more recently, the European Society for Primary Care Gastroenterology have acted as focal points for joint working between general practitioners with an interest in gastrointestinal problems and their specialist colleagues. Through participation in joint symposia and the planning of international conferences, bilateral contributions to the development of clinical practice guidelines and a range of educational initiatives these societies are doing their best to bridge the gap between primary and secondary care.