Almost everybody in Britain who takes an interest in current affairs must sometimes wonder what on earth is going on in the world of medical ‘progress’. On the one hand, every second day seems to bring a breakthrough against cancer or genetic disease – however, every other day seems to bring a new scandal, as some former wonder-drug’s supposed benefits are found to be outweighed by its newly-discovered potential for harm. Surveying the scene as a GP, can any threads be teased out of the confusion?
To reverse the usual order of these things, first a bit of good news to put you in benevolent mood! Some aspects of medicine,without any doubt, have progressed in leaps and bounds over the past few decades.
Try these, for instance:
First, crushing central chest pain strikes – a classic ‘heart attack’, or, in the parlance, an acute myocardial infarction. Not so very long ago (and in the less developed world today), one would have been for bed rest and such painkillers as were available, with survival being largely a matter of fate. Fast forward to today, and the same acute coronary patient is whisked into theatre for emergency interventional procedures to restore the blocked artery’s patency.Long term survival and recovery results have been revolutionised.
Or, witness the cutting edge of research into early-onset (so called Type 1) diabetes. On one track, progress on stem cells and tissue immunology is bringing pancreatic insulin-producing cell transplantation ever nearer, while meantime the engineers are quickly closing in on glucose measurement and insulin dosing systems which will work together as, in effect, a compact external pancreas. Two different approaches, closing in on one goal;normalisation, not just of blood sugar, but of life itself for the diabetes patient.
Sometimes, too, pharmacology can produce an absolute winner of a drug without the hidden harms. Not many years ago,for instance, many lives were blighted by gastric or duodenal ulcer pain. Enter the acid suppressing drugs (and latterly the eradication of campylobacter when present), and thousands have been freed from real misery.
So much for vainglorious trumpeting of our conquest of disease and mortality! What of the downside? Some of my ownpicks might include these:
Exhibit ‘A’, m’lud – ‘polypharmacy’; that is, the tendency for the patient to be prescribed increasing numbers of different drugs to the point of potential harm. As many older readers will be all too well aware, older age comes not alone but with a myriad of recommended pills and potions. Each one will have its own rationale, but much less understood is the combined effect of these powerful combinations, especially in frail patients. Many episodes of confusion, falls, and all kinds of adverse events are thought to be rooted in such well-intentioned but multifarious treatment.
My exhibit ‘B’ is, one might say, the big brother of A, and is what Iona Heath (to me one of the most independent thinkers at the top of the medical tree) calls ‘Disease-Mongering’, or the medicalisation of normal life in order to sell us interventions, whether they be drugs, supplements, plastic surgery or whatever. The controversial new international classification of psychiatric disease is a case in point, creating ‘new’ illness definitions (and thus lines of pharmaceutical profit) for what might previously have passed as variants of normality or natural changes.
So often too, as mentioned above, seemingly ‘blockbuster’ new drug classes will be unmasked over time as being at best equivocal, or at worst downright harmful to health over the long term. It seems nowadays that a few billion dollars to settle the seemingly inevitable class action awsuit in the US virtually has to be factored in to the maker’s price for a new drug.
We can add to the pot such as the apparent cul-de-sac we have reached in antibiotic development, suggesting a future truce with bacteria rather than final victory; our lack of progress against some of the very ‘simplest’ conditions like the common cold; and also the re-emergence of TB in the UK, once thought to be consigned to history.
From all this paradox and seeming chaos, can we as GPs give any useful pointers?
Firstly, strangely enough, we might make a plea for a bit of trust in amongst any understandable scepticism. More and more, our advice and treatments must be backed by solid evidence, or we’re in trouble! The bodies that sift the evidence we find to be generally very impartial in the face of immense pressures.
However, the other side of the coin might be not to be afraid to mix scepticism with your trust! It is perfectly legitimate to ask about, for instance, the downsides and side-effects of any intervention suggested, or even the question the drug companies seem to hate most – ‘ how many people would have to take this medicine in order to prevent one heart attack (or whatever) from happening?’ This number is known for nearly every intervention, and is often none too flattering for the treatment! Don’t forget that you are perfectly entitled to do a bit of research too – health professionals fret about misleading websites, but there are usually some obviously impartial evidence sources well up in the Google rankings if you are on the web.
Most of all, perhaps, batten down the hatches – the haphazard progress of the last few years is liable to get even more confusing as money becomes tighter. The correct prescription might be to take everything you read about health (if not everything you eat!) with the proverbial pinch of salt…
Yours ‘til next time