I’m not after thanks – I’m a GP, so I average a brickbat to bouquet ratio of 10:1. I don’t expect gratitude for ‘preventing’ something that probably wouldn’t have happened anyway. But I wasn’t expecting primary cardiovascular prevention to explode in my face quite so spectacularly.
The story so far: I have traditionally viewed primary prevention as a steaming doggy-do on the pavement of primary care – it stinks, and it’s best avoided. That’s because I have an anaphylactic sensitivity to the dangers – iatrogenesis, medicalisation, neurosis-creation and so on.
But irresistible forces – like NICE, QOF and those poxy health checks pharmacists keep sending us – eventually crushed my resistance. After a while, I even convinced myself that primary prevention was a bit of harmless non-fun – a touch of reassurance here, a sprinkle of statin there. It fed the QOF monster, impressed the few punters who gave a toss and ultimately lulled me into the delusion that I might even be achieving something.
Trouble is, this week has for the first time exposed me to the long-term fallout of messing with people’s cardiovascular risk.
Patient one limps into my consulting room, chucks a box of statins at me and says, lopsidedly: ‘What was the f***ing point of those, then?’ As opening gambits go, it’s pretty impressive. Certainly more impressive than my reply, which is: ‘Ah, I see you’ve had a stroke.’ And, yes, you’re ahead of me. A few years back, after a cholesterol test and some Framingham fiddling, I’d bunged him on a statin because of a red-zone cardiovascular risk, and he’s been taking them religiously. The only religious thing about him now is how he prefaces the phrase: ‘What a bloody waste of time and effort,’ with the words ‘Jesus Christ’.
Then patient two walked in. Unbelievably, another ‘new’ CVA. ‘Gosh, there’s a lot of this about,’ I say, brilliantly misjudging the mood. Because I’m about to be skewered again, but for the opposite reason. This time, I’m guilty of informed inaction.
Why, demands his wife, hadn’t I put him on a statin three years ago when I’d mentioned his cholesterol was slightly high? Because, I point out, as I’d explained at the time, his overall cardiovascular risk had only been 10%, a rationalisation that sounds increasingly hollow as they wave the hospital discharge statin megadoses at me and adopt expressions redefining the word ‘disbelieving’. At least, she does – his face isn’t moving much.
Bollocks. Of course, with patient one, I’d explained at the outset that popping a statin was no guarantee of cardiovascular immunity. And for patient two, I’d pointed out that 10% was below the arbitrary 20% intervention threshold, and simply meant he had a 90% chance, rather than a certainty, of not troubling the stroke or coronary unit in the next decade.
But these nuances, I realise, are firmly forgotten in the overwhelming post-event urge to blame someone. So I’m warning you – it’s more cowpats than doggy-dos, and you can barely see that pavement.