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The ethical fallout of turning people into patient$

Dr Shaba Nabi

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Those of us warning about the ills of overdiagnosis are thankfully no longer on the fringes of medicine, even if doctors making decisions around commissioning and the QOF have yet to get the memo. But it’s only when you come face to face with its consequences personally that you sit up and pay attention.

I am writing this on my annual US holiday to visit family. Nowhere is the ‘too much medicine’ question more relevant, with health obsession and the dollar providing fertile ground. If you wish to see what happens to medical ethics when you taint informed consent with financial incentives, look no further.

People with no apparent health problems are offered a menu of options on an annual basis – reminding me of the three levels of service available when I take my car to the garage. Following his service, my fit American brother-in-law asked me to look at his annual ‘blood work’.

A marginally suppressed TSH (with normal T4 and T3) led to imaging of his thyroid. A PSA of 4.9 triggered a prostate biopsy request. And a slightly elevated cholesterol meant a push for a statin. All these decisions were made following referrals to a specialist, with no dialogue about alternative options.

Would evidence-based lifestyle interventions offer more bang for our buck than screening?

This physician-led agenda is entirely driven by two factors: money and fear of litigation.

Fortunately, my brother-in-law is sensible. He will decline any offer to needle his thyroid ‘nodule’, he requested surveillance for his PSA as he recognised the spurious rise following a bike ride, and he is addressing his lipids through dietary measures. The less motivated or less well informed will inevitably follow the course of dubious medicalisation.

But how different are things in the UK? A ‘big’ birthday while on holiday made me do my own research before being catapulted onto the breast screening conveyer belt. Breast cancer follows the same trend as prostate and thyroid cancer: the graph comparing incidence with mortality/advanced disease is divergent, indicating we’re picking up many more cancers but mortality remains static. This is reinforced by research estimating 10-40% of women aged 40 to 70, not known to have breast cancer, are found to have ductal carcinoma in situ on postmortem.

Are we any good at explaining these odds? I’d rather take my chances and maintain my healthy lifestyle than join the 20% of women likely to have surgery/chemotherapy/radiotherapy for a cancer that was never going to harm me.

I wonder if diverting money from screening programmes into evidence-based lifestyle interventions would offer more bang for our buck, especially as the latter reduce global risk in many long-term conditions.

But I guess that doesn’t fit the business model for doctors in countries where income depends on turning people into patients and it becomes almost impossible to remain purist and put patients’ best interests above your own.

So, if you’re at your wits’ end with chronic NHS underfunding and want to pursue alternative payment models – be careful what you wish for.

Dr Shaba Nabi is a GP trainer in Bristol

 

 

 

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Readers' comments (14)

  • How about treating your patients/the public like adults, Shaba?
    You paint them out to be witless, uninformed children, unable to do their own research or make their own decisions, as compared to what your brother-in-law did of course. At least in the American system, the patient is better encouraged via self-interest to do their research, come to their own decisions, and be both financially and medically responsible to themselves for their decisions. And obviously, others are less compelled (via taxation) to be responsible for them.

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  • Ivan Benett

    Whilst a repeat PSA is important, especially after no vigorous activity or ejaculation, if his level remains above 4 he will have a 30% chance of having prostate cancer. Sure, that means a 70% chance of not having cance. An MRI scan can help but the only real way is a tissue diagnosis. Even so active surveillance is a reasonable option.
    I find that most people when told they have a 30% chance of a cancer that carries significant morbidity, are reluctant to wait and see, notwithstanding their relatives advice.BUT that’s their choice.
    In the issue and fashion for a nihilistic approach to early diagnosis, when faced with the persistent rule of halves I suspect the pendulum has swung too far.
    Of course, as we strive for early diagnosis, we risk over diagnosis. This is one of the costs. But
    patients should be fully informed of this risk before taking the test, knowing that some will be unnecessarily medicalised. Medicine is complex like that. Not black and white, right or wrong, safe or dangerous.
    So many people with diabetes, AF or cancers would prefer early diagnosis. Their chances of avoiding complications or events reduced by early intervention. And some will be unnecessarily medicalised.
    The rule of halves still exists, well maybe the rule of 2/3s since QOF. Sadly this will worsen with the loss of QoF and this populist approach to early diagnosis.

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  • Working for the NHS is not 'pure' either. There is a third person in the room - SOS for health - in each consult. Remember the person who pays is the customer, not the patient.

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  • AlanAlmond

    I agree with Shana entirely. It’s a simple point she is making, and pretty self obvious. Enough with the self indulgent obfuscation already.

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  • AlanAlmond

    I meant Shaba ..sorry autocorrected I guess.

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  • Who's obfuscating here Alan? All you've stated is you agree but no justification for it. She makes a simple point yes and I put up a counter argument. What's yours?

    You might be happy to continue financing an over-inflated and ever-expanding poorly-run state department, but I'm sure there's plenty who aren't.

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  • I agree Shaba - and surely this is also the place to point out the ethically dubious NHS practice of "promoting" screening rather than providing balanced evidence on its benefits and harms.

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  • Christopher- the bad points of the american system are that it is the worlds most expensive with the poorest health outcomes. Simples

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  • n.b. amongst developed countries obvs

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  • Be that as it may, NWdoc, nobody should be compelled to help with somebody else's medical costs. I am even sceptical if the costs include the costs of regulating our tax system to fund the health service, and I don't mean simply the monetary cost but also the siphoning of productive working age adults from the private sector to the bureaucracy. In addition, there are plenty of other countries in the world that run similar insurance-based systems to the USA and have much better outcomes. So your insinuation that the poor outcome in the USA is down to the fact that its insurance-based or expensive is false. Its certainly not as 'simples' as you think.

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