Most of us, in our normal lives outside the surgery, accept a degree of risk. We go on holidays to remote places with poor traffic safety and lousy medical care. We sometimes drive faster than we should. Many of us ski or go up ladders, and a few of us ride motorbikes or climb mountains.
But put us behind our desks and ask us to advise patients and we tell them to spend a lot of time and effort avoiding degrees of risk that we blithely ignore in our own lives.
It is called ‘preventive medicine’ but a better name would be ‘blanket medicine’ or ‘scattergun medicine’, because we basically do not know who is likely to need preventive screening or drugs.
We spend enormous amounts of effort delaying death from cardiovascular disease, which is rapidly declining without our help, for reasons that are unclear but probably have to do with nutrition in utero and early childhood.
Several hundred mild hypertensives have to consume several pills daily to prevent one stroke, and our predictive tools, mostly based on the Framingham study from a small American town 40 years ago, are very poor.
When one of our patients has an MI or a stroke, I tend to have a look to see if we could have predicted it, and apart from patients with known vascular disease, the answer is usually no.
Similarly, examination of the lifestyles of the longest-lived people in the world shows that they are also superficially unremarkable, and do not have very healthy lifestyles. Jeanne Calmet, who died aged 122, did indeed stop smoking – but only at age 117!
The latest fashion is to treat all the elderly who have fractures with bisphosphonates – even if they are unhappily unable to fall over any more because they are wheelchair-bound from their injury.
But do they really expect this treatment to significantly strengthen bones in the patients’ remaining years?
Counting the cost
All this would not matter if it didn’t come with huge costs. Costs in terms of medical time, drug costs, costs for patients in side-effects – bisphosphonates may, for instance, cause oesophageal cancer – and costs too in time and effort.
Above all labelling patients as having conditions they didn’t show any symptoms of, such as high cholesterol or diabetes, has a significant adverse effect on their self-perception, anxiety and overall health.
The odd thing is that when we don’t have our preventive hat on we are prepared to tolerate our patients undergoing some risk.
Joint replacements have a mortality rate of around 1% and will never save a life, and yet we and our patients cheerfully accept that risk because we know the procedure usually improves quality of life hugely.
We are prepared to use treatments like NSAIDs and intra-articular steroids and HRT, even though we know that they do cause serious harm to a few patients on a regular basis.
And which is more satisfying? Patients coming back to tell us that we have cured their symptoms and restored their quality of life, or patients coming back with a better blood pressure but asking if they really have to take those pills?
So please, realise that preventive medicine is largely an illusion. Stop up your ears against the siren calls of the drug industry – and let’s get back to using our common sense.
Dr Ted Willis is a GP in Brigg, North Lincolnshire