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Frog awareness - tidy (Editorial)

Welsh use of the English word 'tidy' is hard to capture. It might be defined as a job well done. Years ago some Welsh GPs used the phrase 'like frogs in a jam-jar' to explain their feelings about centralist diktats, dropped into the jam-jar on top of the frogs. Like 'tidy', 'frogs in a jam-jar', even said without a Welsh accent, is evocative.

Bandolier has long been curious about social policy, believing cynically that academics of that ilk were able to spend longer in the bath than the rest of us. Social policies are rarely examined as closely as medical decisions. The frogs, you see, are under pressure, and not just from the weight of central diktats. The Bandolier school of social policy has an axiom, that those frogs at the coal-face who are humanly and legally responsible for their medical decisions will croak loudly (we hope) if they don't agree with diktats.

Bandolier has stressed repeatedly the important of vigour and quality in assessing evidence, and how that evidence can only ever be a guide, because in the end it is the poor frogs who have to make the coal-face decisions. Yes, the evidence should be their guide, but our frogs must be free to make choices for decisions for which they are held liable.

We all advocate 'baby' aspirin to prevent further problems after myocardial infarction. Never mind that we are a bit woolly about the minimum effective dose, but we should be aware that there is a finite risk of gastrointestinal bleeding even at our (woolly) baby dose ( Bandolier 86 ). Three hundred people at low risk have to take the baby aspirin for one to avoid a further cardiac problem net of major bleeds. Similar issues arise over anticoagulation for atrial fibrillation (more on this on this Bandolier Internet site ).

The problems increasingly are like this: at the end of a Friday surgery (when all the patients were over 80), the last patient (also over 80) has AF. What are the pros and cons of using warfarin in a frail elderly person tenuously hanging on to an independent existence? And what takes precedence in the balancing act of treating AF, hypertension and arthritis? Don't forget that musculoskeletal conditions impact greatest on quality of life ( Bandolier 83 ).

That's why we need intelligent frogs at the coal-face, and not passive implementation, because each patients is unique, and the way they and their carers judge each situation. Coal faces are difficult to see from ivory towers and other high places. A sub-title for good evidence might be as the last bastion of frogs against diktat.

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