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Insurers prescribe cookbook medicine

by Jared Reed  

A worrying precedent may be set for the external regulation of clinical standards by a new melanoma checklist for GPs being developed by an indemnity insurer, the RACGP says.  

Avant is testing new “risk modification guidelines” for melanoma in a pilot program beginning in 2010, in which GPs are given a checklist of 52 points covering clinical knowledge, practice processes, diagnosis, and guidelines for high risk situations.  

“A practitioner following best risk modification practice would be able to agree with each of the statements of the list,” it says.  

But the guidelines are unrealistic, prescriptive and promote “cookbook medicine” by undermining GP clinical competence and judgement, says Associate Professor Jane Smith, Chair of the RACGP’s Queensland Faculty and Skin Cancer Joint Consultative Committee.  

“It’s dictating, it’s cookbook medicine, and it’s wrong. What’s the point of having experts who have had years of professional training and years of experience and years of quality assurance and continuing professional development?” says Dr Smith.  

She says that some sections in the guidelines cover most Australians with an increased risk of melanoma, leaving GPs unable to quantify between the highest risk and lowest risk.    

“A lot of the things they’re proposing are not evidence-based, they may be legally risk averse, but ... I don’t see that there’s medical evidence to support this sort of behaviour,” she tells 6minutes.  

“I still do not see that it is the brief of a medical indemnity company to dictate professional standards and clinical competency.”


26 November 2009
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Latest Comments

  • Cookbook medicine? How dare they! Only the RACGP can dictate professional standards and clinical competency! outrageous!

    Posted by dr kos1nsk1 26/11/2009 3:47:38 PM

  • Well,well,looks like the chefs at the RACGP dont like it when someone else comes up with their own cookbook. Memo RACGP your accreditation standards are a cookbook too.

    No guidelines or book can ever allow for all circumstances in all patients,nor can risk ever be totally eliminated.

    This is why clinical judgement is the key asset of doctors. Sadly whilst the most vital,it is the least appreciated.

    Still perhaps we can all be replaced with trained monkeys who will use the latest guidelines,algorhythms and government approved "best practice".

    Posted by Joe Kosterich 26/11/2009 6:52:18 PM

  • These guidelines are completely unrealistic. It would take me all day to see a single patient!

    Posted by Mimika 26/11/2009 6:56:08 PM

  • I completely agree with Dr Smith about lawyers dictating "clinical guidelines".

    Would they like it if we told them how to do their job, and to disregard all that they had learned?

    Posted by Dr Rosemary Toalster 27/11/2009 10:16:13 AM

  • Despite possibly good intentions, there is so much wrong with these. A quick perusal of these guidelines show that Avant has misrepresented and misquoted the Australian Cancer Network Clinical Practice Guidelines to "support" and "validate" the items in the Avant checklist. There is a mish-mash of general "good practice governance" items which have nothing to do in particular with melanoma, along with what appear to be specialist oriented opinions, rather than evidence based conclusions.

    One particularly jarring recommendation is this: "When GP diagnosis is not possible, images of patients with multiple lesions requiring whole body skin checks are referred to professional mole imaging clinics, where they are available." In Victoria, this means MoleMap, a private company run by dermatologists, some of who reportedly participated in the couple of consultation meetings run by Avant in Melbourne. Such clinics may well prove useful, but there is no body of evidence as yet to support this as a recommendation.

    Most of the other recommendations are supported by Grade C evidence or worse. The only Grade A evidence for melanoma diagnosis from the Australian Cancer Council Guidelines is for doctors to be trained in and use dermoscopy - and this barely rates a mention, let alone emphasis.

    I can see expert witnesses having a field day with this!

    Posted by Dr Jeff Keir 27/11/2009 10:17:26 AM

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