The road less travelled.

660 British Journal of General Practice, December 2012 I think our satnav must be agnostic. It certainly didn’t seem to recognise the existence of a church where a wedding we were due at was about to take place. It took a while to realise that the calm soothing tones coming from our dashboard were leading us nowhere and we had to try and find another way to get to the church on time. Smartphone maps and downloaded instructions from the internet didn’t help either. Thankfully my wife had a brainwave and we stopped and asked some locals the way. Sometimes, despite the huge advances in technology, human/personal knowledge can’t be beaten. At least our satnav wasn’t as malicious as the one that lead Robert Ziegler up a mountain in Switzerland. He followed the instructions from his GPS slavishly until he got stuck on a dangerous, narrow path and had to call the mountain rescue team. Journeys can be complex and risky despite, and sometimes because of, having the most up-to-date technology available. Journeys and pathways appear regularly in NHS management speak. They have become grating clichés for what we used to call clinical care and treatment. It seems to be a way that managers can reassure themselves that health care is controllable in simple terms. Defining a patient’s journey gives an appearance that the complexity of disease and treatment can be codified into a controllable, manageable entity. But below the surface things are not so straightforward. Anybody who spends time on the front line will realise that the complexities of caring for patients don’t always fit in to a neat journey or pathway. Journeys can go wrong, despite the most carefully constructed and validated pathway. We still need to occasionally stop and ask the way from someone else. The Liverpool Care Pathway has been savaged in the press recently. The criticism has been reprehensible. The irresponsible attacks have been unfair, inaccurate, and sensationalised, spreading panic and fear to the most vulnerable. Doctors and especially GPs take a great deal of pride in the ‘grave’ part of caring from ‘cradle to grave’. Left to individuals, care can sometimes be patchy, which leads to unacceptable variations that are bad for patients. Having a well thoughtout structure and framework can be a huge benefit to us clinicians trying to negotiate the challenging situation of deciding when to stop throwing more and more active treatment at a dying patient and start to focus on making sure their symptoms are controlled. There is another side to the coin. Structured guidance can never be a universal substitute for judgement, wisdom, and basic common humanity. I have seen situations where guidelines have been followed too rigidly or sometimes had the absurd comment that I couldn’t keep a patient comfortable because they were not on the ‘pathway’. This is rare but it can happen when a pathway becomes more important than the results it is aiming for. We shouldn’t be lulled into thinking it is a panacea. If the pathway itself becomes the main focus, patients and their families can feel they are not being treated as individuals. They should never get the impression that their journey is along a predetermined conveyor belt. Like justice, medicine needs to be seen to be done as well as be done. I love my shiny gadgets and toys and am usually glad to have the latest structured guidance on dealing with the tricky problems and situations that crop up in medicine. But the more complex and advanced the tools we have the more we need to be able to recognise the times we need to change tack and not follow them slavishly to a dangerous dead end. The malicious debate in the newspapers shouldn’t make us shy away from more serious debates about the nature of guidance, structure, and individual clinical judgement, and to have confidence to do the best for our patients if tensions between them crop up. Pathways should be our tools not our masters.