Saturday, 20 October 2012

Doctor, Doctor, Are All These Pills Really Necessary?

It’s always the same; you wait a week for a story and two come along at once. Just as I was settling down to write about Ben Goldacre’s Bad Pharma, the BBC broke a story reporting that doctors will now face annual appraisals and five-yearly license revalidations. Whereas a doctor could previously work for 40 years without further testing or formal training, as Goldacre’s book observes, these new proposals will ensure that from December, their clinical knowledge and competency will be exposed to regular scrutiny.

In the coverage that resulted from the GMC/DoH announcement, we learnt that perhaps 0.7 per cent of doctors have shortfalls that would be regarded as threats to patient safety. The Telegraph talks about “more than 1,000 bad doctors” – with 129 foundation trusts and 151 primary care trusts in England, this works out to three or four per trust. This might not sound like many, but it’s enough to have the GMC and the Health Secretary worried, and is more worrying still if you’re actually receiving medical treatment.

And here we reach the heart of the matter – public perception. We might like to watch medical dramas, but our understanding of present clinical concerns is far sketchier. Fortunately for the patient, they need never consider medical ethics or whether the benefits of surgery outweigh the risks; they are only compelled to attend appointments, submit to examination, take the prescription they’re offered, languish on a waiting list and sign a consent form. We complain about cuts, budgets and those waiting lists, but we forget that we’re benefitting from a system that remains free at the point of cost – many despair at the state of the NHS, but many others know that they’d be at a loss on their own without it.

For the average patient, seeing phrases like “clitoral enlargement” or “suicidal thoughts or behaviour” on an information sheet, or noting that their newly-prescribed anti-emetic was originally an antipsychotic and can cause dangerous side-effects, is very alarming. Are these conditions permanent, or reversible upon withdrawal? Can I really not even have one drink on these antibiotics? How likely is it they’ll make my contraceptive pill fail? How serious is this headache? Do I need an aspirin, or an ambulance? Who do we even take our questions to? The pharmacist can discuss side-effects and interactions, but may lack the knowledge of the existing condition or potential prognosis to make the right call.

When you consider the complex nature of drug therapy for even a relatively simple symptom, it’s easy to see why a clinician must train for so long: antihistamines used as sleeping pills, antipsychotics for nausea, blood pressure drugs for erectile dysfunction, anticonvulsants for anxiety and migraine, and anti-depressants for seemingly everyone. While each specialism has their own arsenal of relevant drugs, and each consultant will have his own personal favourites, an ongoing and intractable condition can often lead to secondary or off-license uses for unexpected or seemingly unrelated drugs. In this case, a side-effect can become a positive boon.

A number of years ago, a charity I worked for began to see a large number of people with various conditions all being prescribed the same drug; previously used to treat epilepsy, it was now being prescribed for anxiety, depression, personality disorders, neuropathic pain in diabetes, nerve damage through trauma, insomnia, migraines, cluster headaches and sundry other problems. Some patients saw considerable improvements; still others experienced disruptive headaches, terrible nightmares, and serious confusion. Some had it far worse; they found themselves troubled by unwelcome ideas that disrupted their thinking, by suicidal thoughts and urges. It seemed as if the local doctors were throwing the drug at everyone just to see where it worked; we considered ourselves lucky that none of our clients had actually given in to the suggestions and harmed themselves, as had been seen previously with certain antidepressant medications.

As Ben Goldacre observes in his book, doctors cease their lengthy tuition and “spend forty years practising medicine, with very little formal education after their initial training. Medicine changes completely in four decades, and as they try to keep up, doctors are bombarded with information: from adverts that misrepresent the benefits and risks of new medicines; from sales reps who spy on patients’ confidential prescribing records; from colleagues who are quietly paid by drugs companies; from ‘teaching’that is sponsored by industry; from independent ‘academic’ journals that are quietly written by drug company employees; and worse.”

 Perhaps the new checks, dubbed “medical MOTs” (by people who have forgotten, or don’t care, what “MOT” stands for) will assist with this – if a lack of ongoing training make it easy for pharmaceutical companies to exploit knowledge gaps, then maybe identifying and sealing these gaps will make it harder for them to exert their considerable influence. Perhaps this recommendation was introduced as a response to concerns like those shared by Goldacre; perhaps the timing is purely coincidental. We’ll never know, but we can hope that the plans will lead to improvements in clinical education and patient care. We must hope so; we all stand to benefit from it.

This is, of course, the opinion of a lay individual who has spent eight years depending on the NHS’ best and brightest – the pain clinic consultant willing to exhaust every possibility, the patient and gentle GP who took the time to explain the surgery and was more annoyed by the six-month waiting list than I was, the safety net that provides free prescriptions, regardless of quantity or regularity, when one’s luck runs out and unemployment bites. I’ve seen the NHS at its worst, and at its very best.

It is doubtlessly flawed – jetlagged by bureaucracy, slowed by overuse, hobbled by budgets and dented by news story after news story bemoaning all of these faults and more – but it remains the best system available to us. In the main, those of us born after 1950 take it entirely for granted, and those who remember the public reaction to its inception are becoming thin on the ground. It’s been accused of being alternately bloated and pinched, and its relationship with pharmaceutical companies is obviously in need of close examination, but it remains one of our greatest assets. It is, in every possible sense, a lifesaver.

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