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A faulty production line

GPs are the deplorables of medicine

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Brexit and the Trump election. These events have filled plenty of column inches but how this impacts on a sore throat on a wet Wednesday in Widnes is anybody’s guess. This hasn’t stopped the liberal soul searching. Seemingly it is simply ignorant ‘white van men’ in the UK and ‘Deplorables’ in the USA that are to blame for everything. But truth is more uncomfortable than this binary scapegoating.

We are the deplorables of medicine

We the privileged ‘remaining’ elite have our lifestyles off the backs of ordinary men and women. The wealth disparity is huge and social mobility is as common as unicorn on a skateboard smoking a cigar. People are simply fed up with being told how to think, what to say, by an indulged liberal authoritarian elite. An elite intolerant of any dissent, who gives mere lip service of caring for the plight of ordinary working people. 

I am an intellectual chav but this doesn’t mean I don’t understand medical research. The zenith of my undergraduate career is a solitary second class merit in Biochemistry and my postgraduate career was spent in the gleaming spires of Sunderland, Lowestoft and Glasgow. Medical statistics are used to intimidate and confuse but in truth are little more than primary school arithmetic. If a medication works then you hardly need research, for example penicillin. If something doesn’t really work, you need thousands of patients, over years to grind out the positive results. This is the case for the mega-studies into hypertension, cholesterol and osteoporosis. The benefits may be ‘statistically’ significant but in absolute terms the clinical benefits are clinically insignificant. This is the treatment paradox - the overwhelming majority of patients taking medications for decades never directly benefit. GPs know this but prescribe because of guidelines and for fear being denounced and reported, Today’s we live with authoritarian medical correctness.

The Politburo at NICE are considering lowering the hypertension targets to 120/90 [1]. This is based on the SPRINT study of tight hypertension control in older people (average age of 68) published in the highbrow ‘New England Journal of Medicine’. Reading the paper, the numbers needed to treat to prevent stroke death is 1,500 per year and the NNTs to prevent cardiovascular death 500 per year [2]. These are big numbers but consider that an identical study on tight control, called ACCORD, showed no benefit at all [3]. Also a recent Cochrane review challenges whether treating ‘mild hypertension’ is any better than giving patients a placebo [4]. Most telling of all, however, is the numbers need to harm by tight control with ‘serious adverse events’ (falls, syncope, renal failure). In this SPRINT study this was 250 per year.

The signs are that NICE is once again engaging in overhyped numerically illiterate propaganda that will have unforeseen consequences for ordinary people.

This lower target will march into the management of younger populations despite no evidence of benefit. More medication for all, more reviews and ever more pressure in general practice. Modern medicine is making the population paranoid, stealing away wellbeing and undermining life generally. The distant medical elite don’t listen and talks down to GPs. We are the white van men and women of medicine doing the work no one else can do, or is willing to do. Vilified in the media and always to blame. We are the deplorables of medicine, but what to do?

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

References

  1. NICE to look at lowering blood pressure targets in guidance overhaul
  2. The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103-2116
  3. The ACCORD Study Group. Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus. N Engl J Med 2010; 362:1575-1585
  4. Diao D, Wright JM, Cundiff DK, Gueyffier F. Pharmacotherapy for mild hypertension Cochrane Systematic Reviews 2012;(8):CD006742

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Readers' comments (15)

  • The legal test of reasonable behaviour remains that of the Bolam case - would the average reasonable person (GP) have done the same. If everyone follows guidelines slavishly, that becomes 'normal'; if most people think about the individual patient, taking the guideline into account, then that is acceptable in law.

    It's up to you, the GPs still in practice, to make reasonable, thoughtful, behaviour 'normal'. Or not, if you want to treat guidelines as rules, not guidance. Glad I'm retired!

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  • Good article, I have seen so much harm done by doctors obsessively treating people with a dubious diagnosis of hypertension to target.

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  • This is why when the NHS is reinvented from scratch it will need to be about providing impartial diagnostic and prognostic advice for no charge, leaving many 'treatments' to be covered by fees or insurance.

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  • Everyone has their own agenda, be it open to all, or hidden behind closed doors. One consequence of super-specialisation is loss of overall perspective, your area of special interest becomes the most important agenda to push, be it optimum blood pressure to prevent CVS disease, pancreatic cancer diagnosis, identifying and treating skin cancers... but the 'super-specialist' may no longer see the 'patient' in their own context. So the guidelines are generally written by the people most interested in that subject, not necessarily with a 'bigger picture' in mind. Then these documents designed to support us in our management decisions gain increasing importance as guidelines, and ultimately accepted as 'best practice'.
    We, as the generalists with the best overview of both the patient and the medical contexts, need to be able to find the balance between textbook science and real life. Yet it is us, as GPs, who insist on training our future colleagues and successors to follow guidelines as if they were protocols to pass the exams required to follow in our footsteps. How can we expect our trainees to develop the higher judgement skills needed to interpret 'guidelines' in individual cases when we mark them down for not using them- is that not then 'protocol'?
    So, who then is to blame for perpetuating the image of the 'Medical Elite'?...and for GPs becoming the 'Deplorables'? Politicians? Specialists and guideline writers? or us for being base enough not to challenge or lead in guideline writing as expert generalists and balanced interpretation, and just following someone else's lead?
    And another point about our degraded image in the medical world, politics and media...ditch the stigma, rebrand- I am a Rural Physician, an Expert Generalist, a Primary Care Consultant... "GP" is now a tainted title

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  • Brilliant article. For a start has anyone ever met anyone over 50 with a bp

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