Haslam's view: Is seeing really believing?
It seems that every passing year makes me marginally less certain about what I know.
Take the management of back pain. In the past GPs were strongly discouraged from doing lumbar spine X-rays because they were of no proven value.
If you did X-ray these lower backs, just about every patient over the age of 25 had some evidence of ‘wear and tear', which bore precious little relevance to their symptoms. And so, quite rightly, we resisted the pleas of our patients for an X-ray.
What used to drive me to utter distraction was the inevitability that, after having explained this to the patient, the first thing the specialist would do on referral would be to arrange a lumbar spine X-ray. You can imagine what this did for the GP's credibility.
Anyway, that was then. Now we have scans.
MRI scans are astonishing. The absolute clarity they can give of the state of the discs and the potential pressure on the nerves is wondrous to behold. There is a very real incentive to operate because you can see the disc pressing on the nerve and, typically, after the operation the patient gets better.
But now that we have the technology to see the nerves and discs, are there actually more cases that need surgery than there used to be? I'm really not so sure. I had an agonising spell of low back pain about 10 years ago, which reduced me to crawling to the loo on hands and knees. I would bet that an MRI scan would have shown a nerve being compressed. But we didn't have scans, I didn't have an operation, and I did get better.
The simple fact is that the provision of a therapy and the patient's recovery may not be linked. It's tricky – and it will become increasingly difficult to unravel. When a scan clearly and visibly demonstrates pathology, it's very hard to wait and see – even if waiting and seeing may be the best thing to do.
In the management of lower back pain the evidence base seems pretty clear. Advice on exercise works better than most forms of hands-on therapy. Our local NHS physiotherapy service offers an excellent direct access service for patients, with the very best evidence-based advice.
But all too often I see patients who want to be touched, massaged and manipulated. And so they take themselves off to the private sector, where – for the requisite amount of money – they are touched, massaged and manipulated. The evidence base counts for naught. It simply isn't believed.
It's the same with sore throats. We all know there is precious little evidence that the appearance of the throat will be able to guide treatment. The throat may look dreadful and respond to analgesics. It may look normal and be loaded with staphylococci, which may or may not be of relevance.
It has often struck me that there really is little point in asking the patient with a sore throat to open their mouth, but you know full well that, if you don't, they will tell friends, neighbours and anyone else that ‘the doctor didn't even bother to examine me'.
It's often said that justice has to be seen to be done. Medicine has to be seen to be done as well. Although preferably not with an MRI scanner.Author
Professor David Haslam CBE
GP, Ramsey, Cambridgeshire; President, Royal College of General Practitioners; national clinical adviser to the Healthcare Commission; and visiting professor at de Montfort University, Leicester