The first in our three-part serialisation of Dr Margaret McCartney’s book, The Patient Paradox, asks: what do doctors do?
What do doctors do? To my children it’s simple: I make people better. When I go to work, I attend to sick people and get them back to being well. It’s an idea that’s admirable for its simplicity and logic. We are either ill or we are well. If we are well, we have no need of doctors. If we are ill, we should ask a doctor for advice so that we can return to health.
And I do manage this kind of thing, but only rarely. I qualified in medicine in 1994, graduating with a list of things that I had been taught I must never forget, such as Cushing’s syndrome or osteosarcoma or allergic alveolitis. I had been taught by experts and enthusiasts, all anxious that I should realise the importance of their own specialty and, usually, their pet disease (all specialists have these, though they may not admit it.) Not many of these are common to a GP, although there are certain conditions that I am always anxious to recognise because treatment can make someone genuinely better, and this makes for my joy. Hypothyroidism, for example, classically manifests as weight gain, low mood, dry skin and hair that tends to fall out: if you remember to test for it, you can truly make someone better with a blood test or two, and some cheap thyroid hormone tablets. Depression, too, has to be one of the best things to treat as a doctor; it gives me great satisfaction to see an optimistic, happy person re-emerge from the distressed individual who originally sat down with me.
The problem is that I don’t often see, or suspect, Cushing’s syndrome, osteosarcoma or allergic alveolitis. The clear-cut diagnosis promised by medical school textbooks rarely transpires. Instead, I see people who have had a dreadful bereavement and whose income support has been stopped, who are in debt and not sleeping, or who are anxious and scared. The textbooks might say that I should consider depression but the new breed of diagnostic questionnaires, which I am strongly encouraged to use if I suspect depression, do not come with the ability to understand why the person is so afraid. Or someone might present with a pain that sometimes comes when they walk, and sometimes doesn’t, and which is sometimes below the knee and sometimes above it – yet which matches none of the textbook descriptions of anything easily diagnosable or treatable.
So what do doctors do? As someone who felt she had a vocation to practise medicine, and who spends her days trying to work out how to help people, the truth is difficult to admit. It is that medicine has got its priorities muddled up to such an extent that doctors are capable of harming people just as often – or even more often – as they help them.
How? Side-effects of powerful drugs? Misdiagnosis? Wrong operations, or the wrong leg being removed? All these are possible but, to my mind, none is the biggest issue that we face. Side-effects occur with all drugs and must be weighed up against the benefits. I think doctors have got better at criticising drugs and being rightfully cautious about prescriptions. Misdiagnosis? Diagnosis is just as much of an art as a science and is always going to involve subjectivity and some uncertainty. Wrong operations? Human error can be minimised, but never excluded.
All these things are important, but the biggest change to medicine that has arisen over the course of my career has been the seeming determination of healthcare professionals to bring healthy people into surgeries and clinics, and turn them into patients. I am no longer there to make people better, I am there to find out what risk factors for disease they might have or could have, despite their feeling well and having no complaints at all. Shouldn’t general practice be there to deal with people who are in physical or mental pain, who have noticed a worrying lump or who need their diabetes medication adjusted?
Apparently not. Now doctors are there to do cervical smears, to screen for depression, to look for the possible early signs of kidney disease or bowel cancer, to recommend mammography or load people onto weighing scales. Cholesterols, blood pressures and sugar levels are measured millions of times in people who are at low risk of disease. The ‘well person’ clinic is not a service offered ironically. Doctors have even been known to set up ‘well man’ clinics in pubs or football stadiums to ‘reach out’ to people who have no intention of making an appointment. The well are medicine’s new domain.
What’s the problem with that? Isn’t it good that doctors want to prevent illness and disease – isn’t this good for patients, who after all do pay for the whole NHS? How does that old Chinese proverb go? The mediocre doctor treats disease, the excellent doctor prevents it.
Unfortunately, I disagree, which is a shame because as a person of enthusiasm and passion, I would enjoy trying to think of ways to get fit and healthy people in to see me in order to spare them an untimely death. I believe in the moral necessity of reducing the burden of ill health among the poorest people in society. If we could deal with both in a medical double whammy, I would happily devote my time to pulling people off the street and into a blood pressure cuff.
But the reality behind prevention is one of medicine’s dirty little secrets. The cervical screening programme, for example, manages to create a vast number of cervical smears that are ‘borderline’ or ‘abnormal’, causing the need for further testing and enormous anxiety to the women concerned – despite the fact that most changes would revert to normal all by themselves. We look for ways to reduce breast cancer incidence without realising that the biggest problem is the overdiagnosis of cancer on screening mammograms – ‘cancer’ that was always unlikely to maim or kill. We drag people back and forward to the surgery to monitor weight, cholesterol or blood pressure, overlooking the fact that the biggest influences on health are not medicine but poverty, diet, stress and work. And medicine itself is responsible for creating anxiety, needless diagnoses and pointless to-ing and fro-ing from the surgery. People are becoming patients, and there is a cost involved.
And in the meantime, what happens to the people who are depressed, who have found a lump, or who have what might just be Cushing’s disease?
Here is the crunch, the ludicrous inversion of where care is and isn’t forthcoming in today’s NHS. If there is nothing wrong with you, you will receive personalised letters, glossy leaflets, access to special phone lines and kind encouragement to attend for whatever screening tests the NHS would like to offer you.
If you are ill, however, it is entirely different. For those who are anxious and depressed, the so-called talking therapies can be a useful treatment. Accessing them, however, is often a nightmare. You may be asked to phone a number between certain times. Someone may then phone you back to arrange an assessment appointment. At the assessment appointment, you may be told to make another appointment or you may be placed on a waiting list. While on the waiting list, you may be expected to phone regularly to say that you wish to remain on it. When you finally reach the top, you may be told to phone a certain number between certain times or risk losing your place in the queue altogether.
Doing all this when you are well would perhaps be testing. When you are fragile, vulnerable and distressed, it can become nigh-on impossible. Only the least ill may end up getting any help at all.
That’s the paradox that I keep finding within the NHS: if you are ill, you may have to be persistent and determined to get help. GPs have to be persistent too. Yet if you are well, you are at risk of being checked and screened into patienthood, given preventive medication for something you’ll never get, or treated for something you haven’t got.
This book is my attempt to explain this paradox to people at risk of being turned into patients. It is also a plea to the voters, the administrators and the politicians responsible for the NHS to consider what we are trying to achieve and for whom.
What I’d really like to be able to do is agree with my children. Agree that as a doctor, I at least do my best to make ill people better.
To buy The Patient Paradox for £7.49 and free UK delivery (RRP £9.99) visit http://www.pinterandmartin.com and enter Pulse at checkout or call 020 77376868