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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)

  • Great article.

    Very much in keeping with my mantra:
    Common sense - not as common as it used to be.

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  • Sometimes guidelines are simply not mathematical. Like high dose statins.
    Huge side effects with little mathematical [ ie absolute numbers] benefit. It is true. Like calcium 2 tablets bd for years. Does nothing for the failing mesenchymal stem cell or mitochondrion. Yet everyone in every home is on it.
    We have become a bonkers generation.
    PC , no fear of litigation, name in the papers, CQC finger pointing, up before GMC = you did not follow these mad guidelines.
    Sometimes I almost hope that medicine does not survive the law.

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  • Just live in the moment and stay grounded. You work for the government, the government wants you to prescribe statins to your patients. The patients voted for the government. Enough with the self-deprecation.

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  • The art of politics is having someone to blame if things go wrong and taking the credit for other peoples successful efforts . The GP is ideally placed for this role of scapegoat and sap.

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  • great stuff! I like it. Could you tear a chunk out of CQC for all our sakes?

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  • Lets us not forget the "poor" pharma companies - they need us to prescribe :)

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  • Knowledge is Porridge

    Patient: "will these make me live longer?"
    Doctor: "no...but it will FEEL longer"

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  • I am not kidding. I had a conversation with a consultant geriatritian about a 90 y o with historical pubic ramus fracture. She wanted him to start bisphosphonate (despite his very troublesome reflux) and her best argument was that it's as per guidelines and "while there is no evidence that it helps, there is also no evidence that it doesn't". Thankfully patient had more common sense than the consultant, although he did not expect a disagreement between doctors about him.

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  • Absolutely brilliant article. A lot of our decisions are politicised to such an extent and often puts us in difficult positions with our patients - especially in examples such as statins and bisphosphonates. Added to this, the politics of medication that our patients are exposed through conflicting Daily Mail articles stirs things up considerably. Sometimes you can end up (with some patients) at best having a philosophical discussion with little conclusion in the name of "patient choice" or at worst blindly following guidelines which may be inappropriate to the patient re: Vardan Tadevosyan's example. To describe GPs as "we the privileged elite" is spot on. We cannot be helping the people we set out to help within this context - as we are hamstrung within this situation re-affirming and seemingly championing the "indulged liberal authoritarian elite." Our patient's trust in us will diminish in the same way that it has with our politicians.

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  • Are guidelines anything more than a demonstration of the
    pharma-financial interests of the "medical elite" and our alleged: -
    Key Opinion Leaders?


    Isn't it time to demand absolute transparency + chapter and verse of any/every financial benefit received/enjoyed by by our "Guideline Writers".
    My trust in their integrity has evaporated.

    Increasing numbers of patients no longer trust guidelines to be impartial and have ceased to believe that they are written entirely for their own, personal therapeutic benefit.

    Even then, the integrity question remains.

    Declaration of financial interest in a drug is no guarantee that the advocate will not afford self-serving preference in promoting that drug via guidelines, ghost written publications, CME, conference sponsorship and the whole perverse enterprise of marketing masquerading as medicine.

    Time to return to the basic tenets of ethical medical practice?

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