Many women suffer a great deal of heartache before reaching the thin blue line of a positive pregnancy test. There is a large number of infertility treatments and they do not work for everyone, by any means.

Thousands of women take clomifene citrate, a drug that stimulates the ovaries, as part of their attempt to conceive. But a recent study indicates that, for some patients, clomifene is no more help than “expectant management” – doing nothing. The researchers were studying couples receiving treatment at a clinic for “unexplained infertility”, which means that problems such as blocked fallopian tubes had already been excluded.

This paper, published in the British Medical Journal, is interesting for two reasons. First, the National Institute for Health and Clinical Excellence advises that women with unexplained fertility problems “should be informed that clomifene citrate treatment increases the risk of pregnancy, but that this needs to be balanced by the possible risks of treatment, especially multiple pregnancy”.

The remainder of this column can be read here. Please post comments below.

The Lancet has a great editorial today. It’s about the need for guidance for doctors who are asked to assess prisoners who are hunger strikers. They say that doctors should recognise that hunger strike may be the sole method of protest a prisoner has. People who are starving, however, may become confused and disorientated; the difficulty then is to decide whether the person is competent, with medical capacity to decline intervention. Intervention has and is used in this situation, for example in Guantanamo Bay, where prisoners have been, and are, force fed. However, says the Lancet, force feeding has no place in high quality medical care. Independent physicans are required to explain the risks to life that the striker is taking. However, advance directives written by a competent person should mean that if confusion afflicts a prisoner due to a chosen hunger strike, their preordained wishes should be followed.  

Force feeding is not nice. Dr David Nicoll, a neurologist in England, has done a huge amount to highlight this issue (correspondence between him and a previous commander of the Guantanamo military hospital is available here.) The picture of the ‘restraint chair’ that is used is especially harrowing. The bottom line is that individuals with mental capacity have the right to choose what medical care they want - and don’t want. Doctors have to respect that right.

There are yogurts with cholesterol-reducing properties and other dairy products which can supposedly produce “optimal” bowel health. Then there are baked beans with “added omega threes” and drinks that profess to reduce blood pressure. The European Food Safety Authority is now providing “opinions” on the science behind such claims. However a lot of the claims seem to rely on evidence about surrogate markers (eg a product may reduce cholesterol, however what we do not know if this method of reducing cholesterol will go on to have an effect on avoiding heart attacks or stroke.) 

In the end, I suspect that there will not be many adverts rivalling the qualities of ordinary fruit and vegetables -  generally for sale without much in the way of flashy health claims.

I was in central Glasgow last week. On my rainy travails down Buchanan Street, I came across a tent pitched just beside the statue of Donald Dewar. Beside that was a mat on the ground with pictures of hot coals on it, that invited people to try and experience the trial of “chronic pain”. The smiling ladies giving out leaflets were wearing t-shirts saying “Still in pain? Take Control”. The leaflets asked “Are you still suffering?” and offered “Help on discussing neuropathic pain with your doctor”.

Here are some quotes from the leaflet

“When will I feel better? … The ‘right treatment’ for you may mean speaking with your doctor to identify other treatments that may provide greater, long-term, pain relief or fewer side effects. Your doctor may have to prescribe more than one treatment before they find the one that is right for you and this may take time.” Continue reading "Painful conclusions" »

I am perturbed. The US Preventive Services Task Force, a government health body, has decided that doctors should stop offering prostate-cancer screening to men over 75.

It has made a definitive statement: “Do not screen for prostate cancer in men age 75 years or older.” But instead of happy relief at this rare outbreak of common sense, there has been outcry.

Men’s health, the accusations go, is being left out in the cold, for dead. Since I wrote a few lines on this subject on my FT blog, I have received a stream of unhappy e-mails from people distressed that they might now not be recommended to have this “life-saving blood test”. One said: “I feel like I’ve been thrown on the scrapheap.”

The remainder of this column can be read here. Please post comments below.

The World Health Organisation are presenting their findings of a three year investigation into the ’social determinants of health’ today. The report is available here. We are all used to hearing that the latest health news is ’shocking’ and ‘appalling’, but this report is a rare exception - it does actually deserve these descriptions. Life expectancy in one part of Glasgow is falling with a 28 year disparity in one part of the city compared to another. Maternal mortality in Indonesia is 3-4 times higher in the poor compared to the rich. They say “In the United States, 886 202 deaths would have been averted between 1991 and 2000 if mortality rates between white and African Americans were equalized”.

The report is rather brave. It talks about things like ’social justice’ as a way to tackle health inequalities; for example, the importance of good urban developments, the need for fair and decent work, comprehensive social protection, the need for quality and equity in primary health care, and the problems with ‘practices that tolerate or actually promote unfair distribution of and access to power, wealth, and other necessary social resources’.

At the moment the best we seem to be doing to reduce health inequalities is to medicate more people with statins and antihypertensives. The ‘inverse care law’ as described by Julian Tudor Hart, suggests that the more people need medical care, the less they receive it, and I think this is true today. However I do not believe that real improvements in health can be tackled by addressing just access to healthcare. There is only so much that medication can do: low aspirations, unfulfilling employment, financial distress, a lack of  control over one’s life, and little social cohesion have a huge influence on the quality of life and health. These need to be addressed holistically: ’social justice’ is the right term for it.  

‘Health’ I understand. But ’wellness’ ?

‘Wellness’ appears in the dictionary. But it is a mushy, ill-defined, nebulous word that is inherently anti-science (as it has no clear meanings or parameters). I find it to be a very irritating word. ‘Wellness’ is a word which, I have noticed, seems to increase in use in proportion to the money that one is invited to spend on trying to obtain it.

But ‘wellness’ is subjective, and, as a goal, tempts people into new dimensions of worry not just about the absence of disease but also about the depth of exuberant positivity one should bodily and mentally expect to find. It also invites lavish consideration of preventative ‘health checks’, many of which are marginal in potential benefit and most of which come with a flip side of cons. There are drinks, work outs, food, shoes, bras, chairs,  and, of course, health clinics, which come with the promise of ‘wellness’.

Thus, I have spent years trying to dissociate myself from the curse of ’wellness’ in healthcare, and now I have a moral dilemma. I have spent several months trying to find bathroom fittings that will fit into an awkwardly shaped room. I have found the perfect fit. However, the modest fittings are defined as a ‘wellness product’. The search goes on.

It may be summer, but doctors are already ordering stocks of vaccine ready for the flu season.

The NHS pours a lot of money and effort into its annual drive to vaccinate as many people in the high-risk groups as possible, and it has a pretty decent record of doing so. So there’s a good chance that if you are over 65, live or work in a care home (or elsewhere in the health service), have a respiratory disease such as asthma or chronic bronchitis or a condition such as diabetes or heart disease, you will be offered a flu jab free of charge.

The question, however, is whether the NHS should be making such an effort to give you that jab. There have been several reports that vaccinating some of those groups classed as “high risk” does little to cut the risk of complications from flu, for example pneumonia. A paper published in The Lancet this month matched older, healthy people who had received the flu jab with others who hadn’t – and found no evidence that the vaccination reduced the risk of contracting pneumonia. Nor is this the first piece of research to sound a note of caution on the benefits of vaccinating some high risk groups.

The remainder of this column can be read here. Please post comments below.

The latest medical scandal is that dead bodies are left on hospital wards for ‘hours’ before they are taken to the hospital morgue (so says the Herald in Glasgow, the Scotsman in Edinburgh, the Telegraph, the Independent and BBC News) . I discern a distinct lack of a story here.

Dying happens, and I am glad that, as reported, staff on the wards in the hospital thought it appropriate that relatives, friends and chaplains were able to spend some time with the deceased person before the body was removed. That seems humane. While private single rooms are nice, old style Nightingale wards are what the NHS has stocks of. The issue seems to have been that a visiting relative of another (live) patient complained that, on a large ward, and despite the curtains being drawn around the bed, the dead man’s face was visible, uncovered, on a pillow.

Death is sometimes tragic, and often sad, but we do ourselves no favours by attempting to remove ourselves from all witness of it. What, really, do we think happens to our body when we die? The hospitals have apologised, which I am disappointed by; they should have said that caring well for dying people, and caring well for the recently bereaved is immensely important and they are proud of what they have done. There is nothing to apologise for. The inevitability of death is hardly the NHS’s fault.

Moan as we do about the National Institute for Clinical Excellence (NICE), which decides which drugs should be available on the NHS, the idea that there should be a rationale about rationing has been received rather differently across the Atlantic.

In the US $2,000bn is spent annually on healthcare, but only 0.1% of this is actually used to assess whether any of the money was spent wisely, the BMJ reports this week. Two Democratic senators have introduced a bill, which has been generally welcomed, to establish a NICE-like institution to evaluate what the most effective healthcare interventions are. 

The responses to the piece below about NICE’s proposal not to fund new drugs for renal cancer are, in disagreement, understandable. But the problem is that rationing healthcare interventions is inevitable. Even if we (rightly) save money by stopping inappropriate prescribing and other ineffective interventions, there are still going to be limits and hard judgment calls to make. These decisions should be made openly and as fairly as possible.

Continue reading "NICE, not easy" »