“Dad: eggs and salt are bad for you, teacher says.” “Nonsense: you mustn’t believe everything you are taught at school.” There is an art to poaching eggs, and I have one with salt every day for breakfast. I ignore health scares about food, because the more health conscious people are the more miserable they seem to become. Likewise, the benefits of screening or health check ups make no intuitive sense to me. So, on a personal level, I happily ignore the advice of “experts.” Risk is about judgment, and you can be too careful. Life is for living.
But saying no to patients isn’t so easy. They trust doctors: “Whatever you think, doctor.” Likewise, doctors are cuffed by guidelines, telling us to intervene even when we think we shouldn’t. No doctor is criticised for doing too much; the easy thing is always to intervene. So doctors spectate on the march of medicalisation, overdiagnosis, and overtreatment. History will judge our era as one of iatrogenic harm.
And this is a problem with cancer treatments. There have been great advances in treatments and survival (partly because of overdiagnosis of non-progressive disease). And if cancers cannot be cured then many can be contained. But there are unresponsive solid tumours and metastatic disease for which chemotherapy becomes merely palliative, and the prolongation of life is short, if it happens at all. But patients are offered ever more chemotherapy. Most, however, are unaware that it has limited benefit.1 This is wrong.
Chemotherapy involves frequent attendance at hospital, admission, surgical lines, and infusion or transfusion. Patients are put off travelling or seeing family as a consequence. Also, chemotherapy makes patients feel unwell—some mildly, some badly—and is occasionally fatal. Patients become ensnared in the hospital system, often dying in hospital and not at home as many would wish. Worse, it offers false hope. Death is sad, but it must be borne and normalised. Palliative chemotherapy steals away the most precious time.
So why use chemotherapy when it is worse than futile? Perhaps because there is pressure from families and patients “to do something.” Perhaps the media peddle unrealistic expectations. Perhaps patients are on a depersonalised conveyor belt of intervention. Perhaps because of fear of taking away hope. Perhaps doctors are too afraid to talk about death, which we see as professional failure. Certainly, its use is a consequence of a lack of continuity across hospital and general practice. And certainly, it is easier to offer treatment than not. We need to support dignity in death, and this often means saying no to chemotherapy. There is an art to medicine—that is, knowing when to intervene but more importantly knowing when not to too.
Monday, 29 July 2013
Doctors and Recreational Drugs
I drank and smoked at school age. Others picked and took magic mushrooms. Later, when I worked in a pub, some staff always got stoned in the beer cellar, much to my irritation. As a junior doctor, I witnessed the terrible complications of heroin: hepatitis, septicaemia, amputations, and the rest. And in the 1990s, I saw the recreational drug scene kick off—ecstasy, skunk, and then the increasing use of cocaine.
More recently, we have seen the increase in “legal highs,” “club drugs,” and the abuse of prescription drugs. Every generation seems to have a need to misuse mind altering sedatives, stimulants, or hallucinogens. Recreational drugs are everywhere, just under the surface of society and some easily accessible online. There is the perennial debate over control of (and legislation for) these drugs, but this always seems to be behind the curve of use.
There is a high level of self reported drug use—mind you, when did self reporting actually reflect the true prevalence of anything?1 Some drugs are particular to specific communities—for example, khat, a stimulant chewed by east African communities that is legal in the United Kingdom but illegal in many other parts of the world. The acute effects of all recreational drugs are pleasure but also risk taking behaviours. And the come down is depression, paranoia, anxiety, insomnia, or even psychotic episodes. Complications are seen often in general practice, emergency departments, and psychiatry, but are relevant in all specialties. But what do doctors actually know of these drugs? How do we advise patients? How do we manage patients who present with symptoms?
We are taught detailed but irrelevant erroneous pseudoscientific fluff in our medical training, especially about prescribed drugs. But medicine is a social science—about reading people and situations, not just research papers. So why aren’t we taught about recreational drugs, the language, the use, the complications, and the implications for society? Currently, drugs training is limited and focused almost exclusively on heroin and substitute prescribing. There are good online resources about recreational drugs,2 3 but these are basic and no real help in the medical management of drug use in clinical practice. There is a gaping void of academic research into the prevalence, complications, and management of patients taking these drugs that urgently needs filling. A recent government report called for better drugs training for doctors, but progress is painfully slow.4 Recreational drugs are endemic; this is the reality rather than a moral comment. Drugs education likewise should be endemic throughout undergraduate and postgraduate training programmes.
More recently, we have seen the increase in “legal highs,” “club drugs,” and the abuse of prescription drugs. Every generation seems to have a need to misuse mind altering sedatives, stimulants, or hallucinogens. Recreational drugs are everywhere, just under the surface of society and some easily accessible online. There is the perennial debate over control of (and legislation for) these drugs, but this always seems to be behind the curve of use.
There is a high level of self reported drug use—mind you, when did self reporting actually reflect the true prevalence of anything?1 Some drugs are particular to specific communities—for example, khat, a stimulant chewed by east African communities that is legal in the United Kingdom but illegal in many other parts of the world. The acute effects of all recreational drugs are pleasure but also risk taking behaviours. And the come down is depression, paranoia, anxiety, insomnia, or even psychotic episodes. Complications are seen often in general practice, emergency departments, and psychiatry, but are relevant in all specialties. But what do doctors actually know of these drugs? How do we advise patients? How do we manage patients who present with symptoms?
We are taught detailed but irrelevant erroneous pseudoscientific fluff in our medical training, especially about prescribed drugs. But medicine is a social science—about reading people and situations, not just research papers. So why aren’t we taught about recreational drugs, the language, the use, the complications, and the implications for society? Currently, drugs training is limited and focused almost exclusively on heroin and substitute prescribing. There are good online resources about recreational drugs,2 3 but these are basic and no real help in the medical management of drug use in clinical practice. There is a gaping void of academic research into the prevalence, complications, and management of patients taking these drugs that urgently needs filling. A recent government report called for better drugs training for doctors, but progress is painfully slow.4 Recreational drugs are endemic; this is the reality rather than a moral comment. Drugs education likewise should be endemic throughout undergraduate and postgraduate training programmes.
The Dying Deserve Better of GPs
Modern medicine is overcomplicated and pseudoscientific. We talk obsessively of structures and organisations, but in truth quality of care is simple. Being a doctor is about stepping into the breach; quality of care is about taking responsibility.The current problems in the NHS stem from a failure of accountability, leadership, and commitment—and an unwillingness to get involved. This explains the poverty of end of life care and the now discredited Liverpool care pathway.1
I have witnessed too many undignified, distant, and fear filled deaths. Patients should die with dignity, ideally at home with their families and free from unnecessary medical interventions as part of an effort to normalise and demystify death and to aid grieving and the celebration of life. There are many initiatives, working groups, and reviews seeking to promote dying at home2 but these are overcomplicated, mechanistic, and ultimately futile.
As a society if we want people to die at home there is only one solution. General practitioners are to blame for the lamentably few people who currently have a dignified death in their own homes. General practitioners are shirking and shying away from their responsibilities to the dying. Of course, there are barriers—training, time, availability at weekends and evenings, social work support, and all the rest—or are these just excuses?
Although the hospice movement has made great strides in overall quality of care, the unintentional consequence has been abdication of responsibility by primary care, with a terminal dilution of accountability. The current policy of multiagency working is failing. Everyone is notionally involved, but in reality no one person is responsible. We have fractionated care, confused lines of responsibility, and unnecessary polypharmacy. Admission to an acute medical bed is an all too easy and common opt-out.
Palliative care skills are clinically straightforward. General practitioners and district nurses need to seize the agenda and show leadership and should be held directly accountable. They should start visiting patients before death, honestly explaining the futility of treatments, talking in an open and matter of fact way about death. This is not onerous (four to five deaths a year for the average general practitioner) but it takes emotional robustness and commitment. On occasion it involves visiting once or twice a day and overnight and weekend visits when not on duty. This is not part of our contractual obligations but part of our moral contract with patients. General practitioners need to step into this responsibility void in end of life care because it is right and important to do so.
I have witnessed too many undignified, distant, and fear filled deaths. Patients should die with dignity, ideally at home with their families and free from unnecessary medical interventions as part of an effort to normalise and demystify death and to aid grieving and the celebration of life. There are many initiatives, working groups, and reviews seeking to promote dying at home2 but these are overcomplicated, mechanistic, and ultimately futile.
As a society if we want people to die at home there is only one solution. General practitioners are to blame for the lamentably few people who currently have a dignified death in their own homes. General practitioners are shirking and shying away from their responsibilities to the dying. Of course, there are barriers—training, time, availability at weekends and evenings, social work support, and all the rest—or are these just excuses?
Although the hospice movement has made great strides in overall quality of care, the unintentional consequence has been abdication of responsibility by primary care, with a terminal dilution of accountability. The current policy of multiagency working is failing. Everyone is notionally involved, but in reality no one person is responsible. We have fractionated care, confused lines of responsibility, and unnecessary polypharmacy. Admission to an acute medical bed is an all too easy and common opt-out.
Palliative care skills are clinically straightforward. General practitioners and district nurses need to seize the agenda and show leadership and should be held directly accountable. They should start visiting patients before death, honestly explaining the futility of treatments, talking in an open and matter of fact way about death. This is not onerous (four to five deaths a year for the average general practitioner) but it takes emotional robustness and commitment. On occasion it involves visiting once or twice a day and overnight and weekend visits when not on duty. This is not part of our contractual obligations but part of our moral contract with patients. General practitioners need to step into this responsibility void in end of life care because it is right and important to do so.
Bad Medicine : Motherhood
Holding hands and drinking beers, cigarette in mouth, whooping as the sun comes up, best friends forever, piercing, tattoos, mosh pits, vodka, rock festivals, and recreational drugs—this is youth. Never going to conform, to become our neurotic parents, and never trapped in the open prison of the suburbs. Mother Earth-types, free and alive, and happy to give birth under a bush in moonlight. But this isn’t how life works, because we grow up. Friends pair off, and stop going out. Anxiety, once abstract, begins to stalk us—constantly whispering, “What if?” The biological clock rings shrill. Running, no alcohol, and definitely no cigarettes; a health kick to end them all. Anxiety becomes full blown paranoia.
Surely, doctors talk it all down, saying: “Haven’t people been having babies for millennia?” But “carefree” has been surgically removed from today’s expectant parents, who become more paranoid than Mr and Mrs Paranoid of Paranoid Avenue. Nothing is safe; body washes, new cars and furniture, barbecues, oily fish (previously recommended), wrapped foods, cans of all descriptions, and fresh foods are contaminated with pesticides. Remember, says the NHS Choices website, “do not assume safety of products based on the absence of ‘harmful’ chemicals in their ingredient list.”1 All this guidance—on top of avoiding cheese, nuts, mayonnaise,2 children with fever, and even cats3 —is nothing compared with the anxiety caused by antenatal screening, and the devils of alcohol and cigarettes. And this advice is constantly changing and often contradictory, for example, in relation to the benefits and harms of omega 3.4 5 Pregnancy “advice” is great business for books, newspapers, magazines, websites, and television shows—a media bonanza built on fear. But research is observational, theoretical, confounded, and the real risk unknown. Any risk, however, is unacceptable, so we promote this completely unrealistic advice.
Then there is the delivery itself. Women suffer constant medical and surgical interventions. Birth is hospital based, despite uncertainty surrounding whether this is any safer than home births.6 7 A caesarean section rate is driven by social factors, not science,8 with the ever higher rates of caesarean sections not associated with better outcomes.9 Indeed, the United States has the worst rates of neonatal survival of all developed nations.10 In addition, there is the exclusive breast feeding “until six months” diktat, unrealistic and unsupported by a relevant evidence base.11 And this paranoia spills into the rest of childhood, for parents to control and protect against every risk; but life without risk is no life. And we have the rest of life to mess up our children. We are setting mothers up to fail; we make too many feel like bad mothers, and this is bad medicine.
References
↵Bellingham M. Chemical exposures during pregnancy: dealing with potential, but unproven, risks to child health. Scientific impact paper 37, Royal College of Obstetricians and Gynaecologists, May 2013. www.rcog.org.uk/files/rcog-corp/5.6.13ChemicalExposures.pdf.
↵NHS Choices. Foods to avoid. 2013. www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant.aspx#close.
↵Centers for Disease Control and Prevention. Pregnant women and toxoplasmosis. 2010. www.cdc.gov/healthypets/pregnant.htm.
↵Bates C. Women who eat fish during pregnancy “more likely to have brainy and sociable children.” MailOnline 1 February 2012. www.dailymail.co.uk/health/article-2094819/Omega-3-Women-eat-fish-pregnancy-likely-brainy-sociable-children.html.
↵Collins N. Omega-3 supplements “could raise prostate cancer risk.” Telegraph 11 July 2013. www.telegraph.co.uk/health/healthnews/10172445/Omega-3-supplements-could-raise-prostate-cancer-risk.html.
↵de Jonge A, Mesman JA, Manniën J, Zwart JJ, van Dillen J, van Roosmalen J. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands : nationwide cohort study. BMJ2013;346:f3263.Abstract/FREE Full Text
↵Tuffnell D. Place of delivery and adverse outcomes. BMJ2010;341:c5560.FREE Full Text
↵Einarsdóttir K, Haggar F, Pereira G, Leonard H, de Klerk N, Stanley FJ, et al. Role of public and private funding in the rising caesarean section rate: a cohort study. BMJ Open 2013;3:e002789.Abstract/FREE Full Text
↵Jonsdottir G, Smarason AK, Geirsson RT, Bjarnadottir RI. No correlation between cesarean section rates and perinatal mortality of singleton infants over 2,500 g. Acta Obstet Gynecol Scand2009;88:621-3.CrossRefMedline
↵Save the Children. Surviving the first day: state of the world’s mothers 2013. www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf.
↵Fewtrell M, Wilson DC, Booth I, Lucas A. Six months of exclusive breast feeding: how good is the evidence? BMJ2011;342:c5955.CrossRef
Surely, doctors talk it all down, saying: “Haven’t people been having babies for millennia?” But “carefree” has been surgically removed from today’s expectant parents, who become more paranoid than Mr and Mrs Paranoid of Paranoid Avenue. Nothing is safe; body washes, new cars and furniture, barbecues, oily fish (previously recommended), wrapped foods, cans of all descriptions, and fresh foods are contaminated with pesticides. Remember, says the NHS Choices website, “do not assume safety of products based on the absence of ‘harmful’ chemicals in their ingredient list.”1 All this guidance—on top of avoiding cheese, nuts, mayonnaise,2 children with fever, and even cats3 —is nothing compared with the anxiety caused by antenatal screening, and the devils of alcohol and cigarettes. And this advice is constantly changing and often contradictory, for example, in relation to the benefits and harms of omega 3.4 5 Pregnancy “advice” is great business for books, newspapers, magazines, websites, and television shows—a media bonanza built on fear. But research is observational, theoretical, confounded, and the real risk unknown. Any risk, however, is unacceptable, so we promote this completely unrealistic advice.
Then there is the delivery itself. Women suffer constant medical and surgical interventions. Birth is hospital based, despite uncertainty surrounding whether this is any safer than home births.6 7 A caesarean section rate is driven by social factors, not science,8 with the ever higher rates of caesarean sections not associated with better outcomes.9 Indeed, the United States has the worst rates of neonatal survival of all developed nations.10 In addition, there is the exclusive breast feeding “until six months” diktat, unrealistic and unsupported by a relevant evidence base.11 And this paranoia spills into the rest of childhood, for parents to control and protect against every risk; but life without risk is no life. And we have the rest of life to mess up our children. We are setting mothers up to fail; we make too many feel like bad mothers, and this is bad medicine.
References
↵Bellingham M. Chemical exposures during pregnancy: dealing with potential, but unproven, risks to child health. Scientific impact paper 37, Royal College of Obstetricians and Gynaecologists, May 2013. www.rcog.org.uk/files/rcog-corp/5.6.13ChemicalExposures.pdf.
↵NHS Choices. Foods to avoid. 2013. www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant.aspx#close.
↵Centers for Disease Control and Prevention. Pregnant women and toxoplasmosis. 2010. www.cdc.gov/healthypets/pregnant.htm.
↵Bates C. Women who eat fish during pregnancy “more likely to have brainy and sociable children.” MailOnline 1 February 2012. www.dailymail.co.uk/health/article-2094819/Omega-3-Women-eat-fish-pregnancy-likely-brainy-sociable-children.html.
↵Collins N. Omega-3 supplements “could raise prostate cancer risk.” Telegraph 11 July 2013. www.telegraph.co.uk/health/healthnews/10172445/Omega-3-supplements-could-raise-prostate-cancer-risk.html.
↵de Jonge A, Mesman JA, Manniën J, Zwart JJ, van Dillen J, van Roosmalen J. Severe adverse maternal outcomes among low risk women with planned home versus hospital births in the Netherlands : nationwide cohort study. BMJ2013;346:f3263.Abstract/FREE Full Text
↵Tuffnell D. Place of delivery and adverse outcomes. BMJ2010;341:c5560.FREE Full Text
↵Einarsdóttir K, Haggar F, Pereira G, Leonard H, de Klerk N, Stanley FJ, et al. Role of public and private funding in the rising caesarean section rate: a cohort study. BMJ Open 2013;3:e002789.Abstract/FREE Full Text
↵Jonsdottir G, Smarason AK, Geirsson RT, Bjarnadottir RI. No correlation between cesarean section rates and perinatal mortality of singleton infants over 2,500 g. Acta Obstet Gynecol Scand2009;88:621-3.CrossRefMedline
↵Save the Children. Surviving the first day: state of the world’s mothers 2013. www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf.
↵Fewtrell M, Wilson DC, Booth I, Lucas A. Six months of exclusive breast feeding: how good is the evidence? BMJ2011;342:c5955.CrossRef
Monday, 24 June 2013
Get Big Pharma out of Post Graduate Education !
I am wary of the too kind, the too good looking, the too generous, the too polite, the too thin, and the too earnest—because they are always fake. Gullibility is a flaw in medicine, because our job is to give patients what they need, not what they want. Doctors believe their intelligence protects them from pharma marketing but are in complete denial. Doctors follow the herd and are in thrall of the mob.
Big pharma spent £40m last year supporting “educational activity” for health professionals.1 Why? Because sponsored education is just marketing masquerading as education, with the sole intent of influencing doctors. Medicine is a hierarchy, with doctors conditioned to be deferential and to follow orders. So pharma exploits this weakness. It pays hard cash to omniscient and omnipresent preaching specialists. Local consultants are influential, but the international specialist is medicine’s infallible pontiff. And the gravitas of a specialist is measured in research publications, and these in turn are in the gift of big pharma. Many of medicine’s world opinion leaders were anointed by pharma. Experts publish in leading journals, talk on the television, advise governments, work for charities, and sit on international guideline groups.
At a local level, pharma education is about getting access to doctors and establishing personal relationships with pharmaceutical representatives. Big pharma still provides international travel, accommodation, and hospitality to NHS doctors, all hidden from public scrutiny, and this is unacceptable.
The world is changing, with education moving online. Big pharma is on the case, offering free continuing medical education created by third parties, such as sponsored BMJ Learning modules.2 But these independent third parties may become dependent on pharma’s financial support, which will potentially erode independence. Educational sponsorship is about controlling the medical agenda and endorsing a blind therapeutic mindset. It is free medical education sponsored by pharma that has helped spawn overtreatment, polypharmacy, medicalisation, and high costs.
What if pharma didn’t provide education? Radically, doctors could pay for education themselves. We might think twice about jetting off to Florida if we paid personally. Alternatively, education could be provided through easy, cheap and cheerful online modules, forums, and lectures commissioned by the NHS. Also we should have more small local groups for self directed learning. What are the potential levers to change this educational dependence? Firstly, the royal colleges should stop approving continuing medical education from sponsored meetings. Secondly, the General Medical Council should insist that all doctors publish payment and hospitality received as a requirement of registration. Free medical education is too sweet to be wholesome.
Big pharma spent £40m last year supporting “educational activity” for health professionals.1 Why? Because sponsored education is just marketing masquerading as education, with the sole intent of influencing doctors. Medicine is a hierarchy, with doctors conditioned to be deferential and to follow orders. So pharma exploits this weakness. It pays hard cash to omniscient and omnipresent preaching specialists. Local consultants are influential, but the international specialist is medicine’s infallible pontiff. And the gravitas of a specialist is measured in research publications, and these in turn are in the gift of big pharma. Many of medicine’s world opinion leaders were anointed by pharma. Experts publish in leading journals, talk on the television, advise governments, work for charities, and sit on international guideline groups.
At a local level, pharma education is about getting access to doctors and establishing personal relationships with pharmaceutical representatives. Big pharma still provides international travel, accommodation, and hospitality to NHS doctors, all hidden from public scrutiny, and this is unacceptable.
The world is changing, with education moving online. Big pharma is on the case, offering free continuing medical education created by third parties, such as sponsored BMJ Learning modules.2 But these independent third parties may become dependent on pharma’s financial support, which will potentially erode independence. Educational sponsorship is about controlling the medical agenda and endorsing a blind therapeutic mindset. It is free medical education sponsored by pharma that has helped spawn overtreatment, polypharmacy, medicalisation, and high costs.
What if pharma didn’t provide education? Radically, doctors could pay for education themselves. We might think twice about jetting off to Florida if we paid personally. Alternatively, education could be provided through easy, cheap and cheerful online modules, forums, and lectures commissioned by the NHS. Also we should have more small local groups for self directed learning. What are the potential levers to change this educational dependence? Firstly, the royal colleges should stop approving continuing medical education from sponsored meetings. Secondly, the General Medical Council should insist that all doctors publish payment and hospitality received as a requirement of registration. Free medical education is too sweet to be wholesome.
Saying "no" to chemotherapy
“Dad: eggs and salt are bad for you, teacher says.” “Nonsense: you mustn’t believe everything you are taught at school.” There is an art to poaching eggs, and I have one with salt every day for breakfast. I ignore health scares about food, because the more health conscious people are the more miserable they seem to become. Likewise, the benefits of screening or health check ups make no intuitive sense to me. So, on a personal level, I happily ignore the advice of “experts.” Risk is about judgment, and you can be too careful. Life is for living.
But saying no to patients isn’t so easy. They trust doctors: “Whatever you think, doctor.” Likewise, doctors are cuffed by guidelines, telling us to intervene even when we think we shouldn’t. No doctor is criticised for doing too much; the easy thing is always to intervene. So doctors spectate on the march of medicalisation, overdiagnosis, and overtreatment. History will judge our era as one of iatrogenic harm.
And this is a problem with cancer treatments. There have been great advances in treatments and survival (partly because of overdiagnosis of non-progressive disease). And if cancers cannot be cured then many can be contained. But there are unresponsive solid tumours and metastatic disease for which chemotherapy becomes merely palliative, and the prolongation of life is short, if it happens at all. But patients are offered ever more chemotherapy. Most, however, are unaware that it has limited benefit.1 This is wrong.
Chemotherapy involves frequent attendance at hospital, admission, surgical lines, and infusion or transfusion. Patients are put off travelling or seeing family as a consequence. Also, chemotherapy makes patients feel unwell—some mildly, some badly—and is occasionally fatal. Patients become ensnared in the hospital system, often dying in hospital and not at home as many would wish. Worse, it offers false hope. Death is sad, but it must be borne and normalised. Palliative chemotherapy steals away the most precious time.
So why use chemotherapy when it is worse than futile? Perhaps because there is pressure from families and patients “to do something.” Perhaps the media peddle unrealistic expectations. Perhaps patients are on a depersonalised conveyor belt of intervention. Perhaps because of fear of taking away hope. Perhaps doctors are too afraid to talk about death, which we see as professional failure. Certainly, its use is a consequence of a lack of continuity across hospital and general practice. And certainly, it is easier to offer treatment than not. We need to support dignity in death, and this often means saying no to chemotherapy. There is an art to medicine—that is, knowing when to intervene but more importantly knowing when not to too.
But saying no to patients isn’t so easy. They trust doctors: “Whatever you think, doctor.” Likewise, doctors are cuffed by guidelines, telling us to intervene even when we think we shouldn’t. No doctor is criticised for doing too much; the easy thing is always to intervene. So doctors spectate on the march of medicalisation, overdiagnosis, and overtreatment. History will judge our era as one of iatrogenic harm.
And this is a problem with cancer treatments. There have been great advances in treatments and survival (partly because of overdiagnosis of non-progressive disease). And if cancers cannot be cured then many can be contained. But there are unresponsive solid tumours and metastatic disease for which chemotherapy becomes merely palliative, and the prolongation of life is short, if it happens at all. But patients are offered ever more chemotherapy. Most, however, are unaware that it has limited benefit.1 This is wrong.
Chemotherapy involves frequent attendance at hospital, admission, surgical lines, and infusion or transfusion. Patients are put off travelling or seeing family as a consequence. Also, chemotherapy makes patients feel unwell—some mildly, some badly—and is occasionally fatal. Patients become ensnared in the hospital system, often dying in hospital and not at home as many would wish. Worse, it offers false hope. Death is sad, but it must be borne and normalised. Palliative chemotherapy steals away the most precious time.
So why use chemotherapy when it is worse than futile? Perhaps because there is pressure from families and patients “to do something.” Perhaps the media peddle unrealistic expectations. Perhaps patients are on a depersonalised conveyor belt of intervention. Perhaps because of fear of taking away hope. Perhaps doctors are too afraid to talk about death, which we see as professional failure. Certainly, its use is a consequence of a lack of continuity across hospital and general practice. And certainly, it is easier to offer treatment than not. We need to support dignity in death, and this often means saying no to chemotherapy. There is an art to medicine—that is, knowing when to intervene but more importantly knowing when not to too.
Friday, 21 June 2013
Bad Medicine: Statins
An old man told me how the two boys be sat beside at school died in a Diphtheria out break in the 1920s. But Diphtheria, Tetanus , Epiglotitis , measles and hopefully soon bacterial meningitis are illnesses of the past. Today Infectious disease consultants are left playing table tennis in the Doctors mess. Vaccination is medicines miracle , protecting individual and the public health . The anti-vaccination lobby is illogical. Today’s courageous public health policy is the suggestion of offering statins to all the middle aged to prevent vascular disease. For a recent Cochrane review states that that statins are safe and effective in primary prevention [1] , with another meta-analysis reporting statins effective even in low risk groups.[ 2 ] There is no longer a ”normal” cholesterol level. Is treating everyone over a certain age good medicine ?
The cardiovascular disease model is a paradigm based on risk factors , all now morphed into “diseases” . Cholesterol , Glucose, and the elasticity of arteries based assessed by a Victorian hearing aid ! Yet you can fly a jumbo-jet between the confidence intervals that support this model [ 3,4 ] A simplistic model is riven many paradoxes. Like the declined in vascular disease predating modern medications by decades.[5 ] Also we are told vascular disease is a product of modern lifestyle but a study irrefutably demonstrates IHD was common in prehistory. [ 6] .And why has vascular disease not increased with the increase in diabetes and obesity ? [7] But medicine believes in this model , worshipping at the educational cathedrals of the pharmaceutical industry.
Also, the effects of statins need quantified. In those low risk over 60 on standard statin treatments, the NNT per year to prevent cardiovascular events is 450 and to prevent vascular death 1250 [ 2] So unlike vaccination , virtually none of these patients will actually benefit directly despite taking statin for the rest of their lives. For any benefits are seen only at a population level, this the treatment paradox. And with much of statin research now twenty years old , since then background incidence has halved, these NNTs could have doubled. Finally , already we prescribe 60 million statins yearly [8] , so why can’t we categorically prove that statins work in the real world? What happens if there is some unforeseen long term side effect ?
But skeptism is futile. Guidelines will be issued expanding statin use , and these orders dutifully followed. Patients trust Doctors, will go along with this advice , eroding societies wellbeing and fanning health anxiety. Soon the natural extension of this logic will see a clammer for statins ever younger age groups and for more aggressive treatment. Is statins-for-all bad medicine ? Time will tell.
[ 1] Taylor, F Statins for the primary prevention of cardiovascular disease The Cochrane Library Published Online: 31 JAN 2013
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004816.pub5/abstract;jsessionid=C0661B00F5EDB2EA82F39DE3DFF254A6.d02t04?systemMessage=Wiley+Online+Library+will+be+disrupted+on+18+May+from+10%3A00-12%3A00+BST+%2805%3A00-07%3A00+EDT%29+for+essential+maintenance
[2] Cholesterol Treatment Trialists' (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012; 380: 581-590
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60367-5/abstract
[ 3] Piotr Bandosz Decline in mortality from coronary heart disease in Poland after socioeconomic transformation: modelling studyBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.d8136 (Published 25 January 2012)
http://www.bmj.com/content/344/bmj.d8136?ijkey=f78faf5310aa29bf473519585cac7c06e1218d01&keytype2=tf_ipsecsha&linkType=ABST&journalCode=bmj&resid=344/jan25_2/d8136&atom=/bmj/344/bmj.d7809.atom
[ 4 ] Belgin Unal Modelling the decline in coronary heart disease deaths in England and Wales , 1981-2000: comparing contributions from primary prevention and secondary prevention BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.38561.633345.8) http://www.bmj.com/content/331/7517/614
[ 5] CDC Achievements in Public Health, 1900-1999: Decline in Deaths from Heart Disease and Stroke -- United States, 1900-1999 August6, 1999 / 48(30);649-656 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm
[ 6] Thompson R Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations The Lancet, Volume 381, Issue 9873, Pages 1211 - 1222, 6 April 2013http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60598-X/abstract
[ 7] Wang C Health and economic burden of the projected obesity trends in the USA and the UK The Lancet Volume 378, Issue 9793, 27 August–2 September 2011, Pages 815–825
http://www.sciencedirect.com/science/article/pii/S0140673611608143
[8 ] Health and Social Care Information Centre. Prescription Cost Analysis— England , 2012. April 2013.
www.hscic.gov.uk/catalogue/PUB10610
The cardiovascular disease model is a paradigm based on risk factors , all now morphed into “diseases” . Cholesterol , Glucose, and the elasticity of arteries based assessed by a Victorian hearing aid ! Yet you can fly a jumbo-jet between the confidence intervals that support this model [ 3,4 ] A simplistic model is riven many paradoxes. Like the declined in vascular disease predating modern medications by decades.[5 ] Also we are told vascular disease is a product of modern lifestyle but a study irrefutably demonstrates IHD was common in prehistory. [ 6] .And why has vascular disease not increased with the increase in diabetes and obesity ? [7] But medicine believes in this model , worshipping at the educational cathedrals of the pharmaceutical industry.
Also, the effects of statins need quantified. In those low risk over 60 on standard statin treatments, the NNT per year to prevent cardiovascular events is 450 and to prevent vascular death 1250 [ 2] So unlike vaccination , virtually none of these patients will actually benefit directly despite taking statin for the rest of their lives. For any benefits are seen only at a population level, this the treatment paradox. And with much of statin research now twenty years old , since then background incidence has halved, these NNTs could have doubled. Finally , already we prescribe 60 million statins yearly [8] , so why can’t we categorically prove that statins work in the real world? What happens if there is some unforeseen long term side effect ?
But skeptism is futile. Guidelines will be issued expanding statin use , and these orders dutifully followed. Patients trust Doctors, will go along with this advice , eroding societies wellbeing and fanning health anxiety. Soon the natural extension of this logic will see a clammer for statins ever younger age groups and for more aggressive treatment. Is statins-for-all bad medicine ? Time will tell.
[ 1] Taylor, F Statins for the primary prevention of cardiovascular disease The Cochrane Library Published Online: 31 JAN 2013
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004816.pub5/abstract;jsessionid=C0661B00F5EDB2EA82F39DE3DFF254A6.d02t04?systemMessage=Wiley+Online+Library+will+be+disrupted+on+18+May+from+10%3A00-12%3A00+BST+%2805%3A00-07%3A00+EDT%29+for+essential+maintenance
[2] Cholesterol Treatment Trialists' (CTT) Collaborators. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012; 380: 581-590
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60367-5/abstract
[ 3] Piotr Bandosz Decline in mortality from coronary heart disease in Poland after socioeconomic transformation: modelling studyBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.d8136 (Published 25 January 2012)
http://www.bmj.com/content/344/bmj.d8136?ijkey=f78faf5310aa29bf473519585cac7c06e1218d01&keytype2=tf_ipsecsha&linkType=ABST&journalCode=bmj&resid=344/jan25_2/d8136&atom=/bmj/344/bmj.d7809.atom
[ 4 ] Belgin Unal Modelling the decline in coronary heart disease deaths in England and Wales , 1981-2000: comparing contributions from primary prevention and secondary prevention BMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.38561.633345.8) http://www.bmj.com/content/331/7517/614
[ 5] CDC Achievements in Public Health, 1900-1999: Decline in Deaths from Heart Disease and Stroke -- United States, 1900-1999 August6, 1999 / 48(30);649-656 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a1.htm
[ 6] Thompson R Atherosclerosis across 4000 years of human history: the Horus study of four ancient populations The Lancet, Volume 381, Issue 9873, Pages 1211 - 1222, 6 April 2013http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60598-X/abstract
[ 7] Wang C Health and economic burden of the projected obesity trends in the USA and the UK The Lancet Volume 378, Issue 9793, 27 August–2 September 2011, Pages 815–825
http://www.sciencedirect.com/science/article/pii/S0140673611608143
[8 ] Health and Social Care Information Centre. Prescription Cost Analysis— England , 2012. April 2013.
www.hscic.gov.uk/catalogue/PUB10610
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