Questions asked about the value and effectiveness of modern medicine

I was talking with a colleague last night whose wife is a doctor. He bemoaned the fact that there is a trend in the UK for closure of hospitals. The automatic reaction many of us have to the cutting of health services is that it’s a bad thing, and that people will lose out as a result. There is of course potential for people to suffer as health services contract, but the relationship between quantity of healthcare and the health of population is not as straightforward as we might think.

Recently, I was reading a piece in the British Medical Journal (BMJ) about some research which finds that in areas where there is more healthcare, more people get diagnosed with illness compared to areas with less available medical care. The overall death rates, however, are essentially the same. One might be tempted to think then the additional medical care in the first setting is keeping sicker people alive. Actually, the research found that the real explanation is that the individuals in the first setting just appear to be sicker. Why? Because they have more interaction with medical care and are more likely to wind up with a diagnosis [1].

Reading this reminded my of another piece of research, also published in the BMJ, which reviewed the effectiveness of ‘health checks’, like having your blood pressure, cholesterol and body weight checked and the appropriate advice or medical care dispensed as a result. 14 studies were analysed. Overall, this sort of health screening made no difference to rates of illness or death [2].

The authors of this study also added that: “Important harmful outcomes were often not studied or report.” It is possible that health checks will pick up ‘problems’ that do not exist in reality or would not have bothered the individual if left alone, but still may result in treatment that can be hazardous or even fatal. Although not a focus in this research, mammography is a classic example of a screening test that has the potential to do much harm.

This week, the BMJ published a letter [3] from a UK General Practitioner (Family Physician)which included this passage:

We feel the consequences of overdiagnosis keenly in British general practice, where a huge part of our workload now revolves around the implementation and fallout of systematic population based screening and risk factor modification. Many of us are wondering if things are getting a little out of hand.

Last month, the BMJ launched an initiative branded ‘Too Much Medicine’ which seeks to “explore the causes and potential remedies of overinvestigation, overdiagnosis, and overtreatment.” I wholeheartedly support this initiative, as it’s likely to help us doctors better understand what aspects of medical care actually do people good. My sense is many cherished practices will fail when viewed objectively. I won’t be surprised if we turn up a few things that are downright hazardous too.

Sometimes, in medicine, the best thing to do is nothing. And I am reminded of a phrase (attributed to one Dr Linda Lewis) that neatly encapsulates this concept and might be headed by doctors more often: “Don’t just do something – stand there!”

References:

1. Wennberg JE, et al. Observational intensity bias associated with illness adjustment: cross sectional analysis of insurance claims BMJ 2013;346 doi: http://dx.doi.org/10.1136/bmj.f549 (Published 21 February 2013)

2. Gøtzsche PC, et al. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345:e7191 (Published 20 November 2012)

3. Treadwell JS. GPs—Do you want to join the debate on overdiagnosis? BMJ 2013;346:f1728

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12 Responses to Questions asked about the value and effectiveness of modern medicine

  1. PhilT 22 March 2013 at 10:57 am #

    As the UK NHS is “free at the point of use” is it not simple economics that “in areas where there is more healthcare, more people get diagnosed with illness compared to areas with less available medical care” – our appetite for consuming a free good or service is unrestrained.

    If we have to wait 3 weeks to see the GP we’re going to see them less often than if we can get an appointment the same day.

  2. Stella 22 March 2013 at 5:52 pm #

    I wonder if it’s more to do with BigPharma that more people are diagnosed with problems that don’t really affect people’s daily lives. In fact they are not ill, just have a different set of bloods etc than the accepted norm. Of course you will always find what you’re looking for whether it is positive or negative. We all know that statistics can be found to support or deny any viewpoint.

  3. Lorna 22 March 2013 at 6:34 pm #

    Dr James LeFanu has a phrase he uses in his excellent review of the medical ‘advances’ in the 20th Century in his book: ‘The Rise and Fall of Modern Medicine’. He calls us in the Western World ‘the worried well’. He describes 12 ‘Definitive Moments’ early last Century when medicine was making enormous progress in improving the health of the nation. He then goes to to explore ‘The Fall’ of modern medicine and attributes at least some of this to the ongoing quest for ailments to treat that do not, necessarily, need intervention. Here, then, is another medical professional who sees we are at a watershed: increasing prescriptions for the general population do not equate unequivocally into better health. And compared to last Friday’s appeals for £5 for malaria drugs for children in Uganda, it seems almost indulgent on the part of us ‘patients’ and ‘greedy’ on the part of Big Pharma.

  4. Joyce 22 March 2013 at 6:54 pm #

    What I would like to know is…who made the menopause an “illness”..

  5. Lorna 23 March 2013 at 2:37 pm #

    To # Joyce: maybe it was the manufacturers of HRT???

  6. Anne 24 March 2013 at 2:19 pm #

    Over medication of people needs a mind-set change from both doctors and patients/the public. Menopause is not an illness, and neither is cholesterol or blood pressure. BUt we spend billions each year on drugs for these supposed ‘conditions’. In 2010, cardiovascular drug spend was £1.5 billion and 63% of this was on lipid-lowering drugs (mainly statins) and blood pressure lowering drugs. That’s a whooping £960million. Surprise, surprise, a recent Cochrane review found no evidence of effect on mortality, strokes, heart attacks etc on treating patients with mild hypertension with blood pressure-lowering drugs. What was even more interesting was that ‘mild’ hypertension was identified as between 140-159mm/Hg over 90-99mm/Hg. This is completely at odds with NHS definition of hypertension as being 140/90mmHg. Its no wonder we are over-medicated, especially when GP incentives and performance targets are tied into such rubbish.

  7. Andrew 26 March 2013 at 8:51 am #

    As per Anne, I was amazed at the level which the report settled on a BP to be mild hypertension.

    I know in America that with a lot of lobbying they have reduced the levels to being 120< / 80< as normal, anything higher as being pre-hpyertension and over 140/90 as high blood pressure.

    Does anyone really know? What are the differences in outcome since the old 100+ your age was replaced in the UK? I would have thought as the human body changes due to age that BP would also change, so the 100+ your age seems a reasonable assumption.

    The problem I have with all these "safe" levels is that it is pretty unclear if they are being set at levels for public health or for shareholders bank balance health. Mostly the lobbying is done using stastics and % improvements in so called outcomes, these are so easy to manipulate that it becomes all smoke and mirrors.

  8. John Duggan 28 March 2013 at 8:22 pm #

    Well, it is hardly a surprise that, if you define downwards the level at which a person is considered to be “sick”, you are going to have a lot more opportunity to “treat” them. I don’t want to be sycophantic about Dr Briffa’s challenging of accepted wisdom but it is really frightening now much of standard practice appears to be based on no objective research or observation
    “Do no harm” is a terrifyingly overlooked principle of modern medicine.

  9. Chris 30 March 2013 at 11:23 am #

    The trajectory of human evolution involves a long and slow process whereby the business of provisioning the ‘necessaries of life’ has required steadily deceasing units of human input and effort. Then as we ventured into modernity the agricultural revolution spawned the industrial and post-industrial revolutions, that greatly exponentiated the effects of this long trend.The inputs of relatively few people are required to physically provision the things that satisfy actual ‘need’. This is good because we have more time to create luxuries and amusing gizmos. But there is also a downside.
    Societies are under the subtle but striking influence of something at large amongst them that discourages any ‘throttling-back’. The problem is that all these proficiency and efficiency gains displace people from employment, thus creating great pressure to create new goods, new services, along with new markets and emergent industries. Economists, politicians, society and decent people have become indentured to the growth and efficiency imperative(s). The emergent markets, some of them ‘good’, have also involved in activities that blend the advantages of trade with disadvantages of trade-off.
    it is unfortunate, not easy for an individual to perceive without some investment of time and effort, but modern medicine and many a contemporary general practitioner has been co-opted into the this phenomenon of trade and trade-off.
    Aspects of modern food, modern health mantras, and even the contemporary distribution of wealth and indebtedness encourage people to forsake good food for the less good. This leads to physiological duress that can lead in time to illness. healthy people are converted to patients, and then in turn patients must be converted to ‘consumers’. The low-input solution of prevention by interfering in the causal relationship would diminish opportunities for ‘trade’. More trade is possible if we encourage people to get sick and then ‘treat’ them. ‘Treatment’ scarcely embraces the noble cause of prevention, pays lip service to cure and prefers the involved and profitable pathway, but managing ill-health has become the norm.
    People readily describe excessive currency trading as ‘casino capitalism’, but some of the agenda within the modern food-chain and modern medicine has become an alliance that gambles with peoples lives, or quality of life. That’s an example of trade and trade-off, I feel. It’s no longer enough to be able to provision goods and services people need, now we must induce them into purchasing things they could well do without. If only there was away to escape the grasp of the growth imperative .. .. .. and oddly there is.

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