Monthly Archives: November 2008

When I was at medical school, hormone replacement therapy was not just the treatment of choice for the flushes and sweats of menopause. It was also thought to reduce the risk of heart attacks, strokes, dementia, colon cancer, bone and even teeth loss.

Yet over the past few years new research has made many doctors reluctant to prescribe HRT in the longer term. Their concern stems mainly from a study conducted during the US Women’s Health Initiative (WHI), a government-funded project to investigate the health of postmenopausal women.

The large, randomised, placebo-controlled trial was stopped early, in 2002, when researchers became concerned by the increased rate of heart attacks and strokes in the HRT group, compared with those taking the placebo. HRT did seem to reduce the rate of bone fractures and colon cancer, but the investigators decided that the adverse effects outweighed the beneficial ones. In the UK, research projects such as the Million Women Study have also found HRT to prompt side-effects such as breast and ovarian cancers.

The remainder of the article can be read here. Please post comments below.

Medical lore has created something of a cult around the measurement of children’s temperatures.

A fever seems to be something which is suspected and then recorded, swiftly followed by the administration of medicine to “bring it down”.

Some confessions. My home medical kit isn’t up to much. At one point it did contain a thermometer, which came free with a purchase at a petrol station and subsequently broke. It was a complement to what I saw as the only vital medical accessory for a household with children: infant paracetamol.

The remainder of the article can be read here. Please post comments below.

When it was announced that both the presidential candidates were allowing sight of medical information about them to be read and reported on by journalists, I was slightly perturbed. Sure, I could see that perhaps the knowledge that one had no outstanding concerns with their health might – might – have some kind of relevance to an election.

But not really. First of all, while we can say that we are fine “at the moment” who knows what may be around the corner? Not everyone has risk factors for the illnesses that they will later die of. Medical “check-ups” are seriously limited in their abilities to offer a prognosis of any value. And in the case of a declaration of illness, disease or even risk factors for disease, how then can an electorate fairly decide if this will affect the ability to hold office? Many illnesses or disabilities need nothing more than the correct type of support or treatment. The real problem with the declaration of some health issues is not so much the disability that this may or may not reveal, but the disability that the public may imagine.

Lord Owen thinks we should be borrowing pages from the US book. He writes in the British Medical Journal this week: “Everyone who wishes to put themselves forward to the electorate as a potential national leader ought to be compelled by party rules to submit to an independent health examination that doesn’t involve their personal doctors and that is assessed by people of proven independence. This would not run into conflict with any existing legislation protecting the rights of the individual. If potential candidates knew they faced independent assessment and that they had a health problem then either they would not stand or they would make it public of their own volition. For example, John Kennedy, in 1960, believed that he would never be elected president if he admitted he had severe Addison’s disease. Yet there is no reason why someone who has Addison’s disease should not be US president if it is well controlled with replacement therapy.”

This is contradictory, unfair, and oppositional to the tenet that doctors should be first an advocate for the patient, and capable of a confidential professional relationship with them. Why on earth should JFK have “admitted” (in itself a pejorative term) to a condition which Owen rightly says need have had no impact on his abilities in office?

Owen also brings up the issue of Tony Blair and his heart irregularity which he says was not, as was contemporaneously reported, a new issue, but an old one.  “I do not believe it is in the public interest that this situation be allowed to continue,” Owen writes, wishing all this information to be placed in the public domain. But these type of heart rhythms are common, and readily treatable, and I can think of no reason why this should stop someone from being PM. What is the point of the public knowing about it? None. It is personal information, and even world leaders are entitled to have privacy.

So what kind of health problem should stop people declaring themselves a potential leader? I know people with metastatic cancer who have stable health, and who are also insightful and thoughtful. I know people who have major mental illness who are not only capable but who work in partnership with health professionals such that they can remain insightful and well. I know people with heart disease who have not stopped from being the same impressive businesspeople that they always were. Nor would I wish to restrict the groups of people who would hope to lead the country to those who are happy for their medical records to be laid bare. This introduces a dangerous bias. Egotism, overconfidence and irrationality are the qualities I most fear in politicians, and none of these are medical conditions.

I am taking a break from the blog for a week or two and will catch up then. 

The only thing separating reiki and reflexology from rational medicine and progress is evidence. And what evidence-based aficionados like me love best is the randomised controlled trial, the process by which most drugs and treatments aspire to be tested. But are we now hearing its death rattle?

In a recent lecture at the Royal College of Physicians, Professor Sir Michael Rawlins appeared to have stuck the knife in the randomised controlled trial. Sir Michael, chairman of the National Institute for Health and Clinical Excellence, effectively said that such trials weren’t the be-all and end-all. “Sir Michael Rawlins attacks traditional ways of assessing evidence”, the story went. But it is not the value of these trials that is the problem, but rather how we chose to think about their conclusions.

The remainder of the article can be read here. Please post comments below.

Much ado with a new paper published by the New England Journal of Medicine . This study was placebo controlled and focused on treating people with ”normal” cholesterol but a high “c-reactive protein” (a marker of inflammation) with rosuvastatin (which is not a new statin as some media outlets have reported, but one already in use). Reports have been rather enthusiastic, eg from the Daily Telegraph: ” risk of a heart attack was reduced by 54%”. One doctor is reported as saying it’s “astonishing”. The trial was stopped early due to “remarkable” results.

The problem is that although the “54%” looks marvellous, and is true, this is the relative risk reduction, not the absolute risk reduction. It does not, by itself, give us a true picture of how meaningful this reduction in cardiovascular events is. We have to know what our risk of having such an event was to start with. From “table 3″ in the paper, the number of patients in the rosuvastatin group was 8901. The number of heart attacks in this group was 31. The placebo group was also made up of 8901 people. The number of heart attacks in the placebo group was 68.  The chance of this group of people having a heart attack on placebo treatment was 68/8901, or 0.76%. The chance of the other group of people, those on rosuvastatin, having a heart attack were 31/8901, or 0.35%. Thus, if you have a normal cholesterol but a high CRP, and if you take rosuvastatin, you can have a 0.35% chance of having a heart attack as opposed to a 0.76% chance.

I’m not very impressed. The other problem with this trial is that it was stopped early. Thus we don’t know what the long term benefits or problems of this approach were (article on this here) . And there did seem to be a small increased risk of developing diabetes in the rosuvastatin group.

However, there may be something else going on here. I mentioned the thought-provoking book The Cholesterol Con by Dr Malcolm Kendrick a while ago. He says, effectively, that cholesterol is nothing to do with heart disease. Statins seem to have some effect on outcomes, but probably have another way of working which has nothing to do with cholesterol, but something to do with inflammation.

“GlaxoSmithKline is to make public the level of advisory fees it offers to doctors and medical academics, and will strictly cap the payments they can receive in the US to $150,000 (£88,000) a year each. Andrew Witty, chief executive of the UK-based pharmaceutical company, said he was introducing tougher new rules to impose a cap “without exception” on such payments and promised to publish the amounts.”

I’m catching up with my reading. Andrew Jack interviewed Andrew Witty, the chief exec of GSK, in the FT a week or two ago. That’s the first paragraph of a very interesting piece. 

Now, publishing the amounts GSK pay doctors is very good, but, er, 88K a year? For a couple of lectures and lending one’s name to a bit of ghost-writing? GSK, please save your cash and don’t pay any doctors not wholly employed by you for any advisory anythings. Last year the kickbacks received by orthopaedic surgeons – some up to $1m worth – in the US were revealed after a federal investigation showed just how closely doctors and the orthopaedic industry were “working”.  There is still cash being thrown at doctors in the UK. I am tired of throwing out all the invitations I get to hearing the latest on cardiac risk factors/obesity management/urinary incontience over dinner at very nice restaurants courtesy of pharmaceutical reps.

Would you want the advice of a doctor who has just been eating canapes courtesy of the latest anti-inflammatory rep? Would you take the recommendation for your type of hip replacements from someone who has just spent a few five star days giving “consultancy” to the manufacturers?

I hope not. Medicine is difficult enough without having one’s judgment impaired by biased interpretations of the evidence. There is lots of dialogue to be had between doctors and both the pharmaceutical and medical device industries. But this should be done without personal gain. 

That should be obvious. Professionals should not be technicians who can be puppeteered at the whim of the sponsor; they should be acting for the best interests of those they serve with 20/20 clarity. That’s surely the bare minimum we should expect as patients, from doctors?

Every time I have written about this I have had emails from doctors who tell me that I am a fool. You can have nice dinners and lux conference stays and still be a pro, they say, I can’t be bought! But of course you can. Anyone can. The point of being a professional is surely that you choose not to be.

Free newspapers, a takeaway menu, special offers from the supermarket and, in the pile of mail cascading on to the doormat, a glossy leaflet from a health clinic, advertising a special check-up service.

“Put your mind at ease with a health check from Lifescan, the UK’s leading provider of private CT assessments,” it said, alongside pictures of glowingly healthy people. “Wouldn’t it be reassuring to be given a clean bill of health,” the leaflet went on, before asking: “Would you benefit from a Lifescan health check? Certain things can put your health at risk – smoking, for example, or if your family has a history of heart disease, stroke or cancer. So, too, can diabetes, high blood pressure or high cholesterol, and a stressful or sedentary lifestyle.”

The remainder of the article can be read here. Please post comments below.

The Advertising Standards Authority have announced that they are upholding my three complaints against a leaflet about Lifescan. You and Yours are doing a piece about it at noon today. More on this later.

Alan Johnson, the Health Secretary, has announced that patients will now be allowed to buy and be treated with medicines not available on the NHS – but without affecting that person’s entitlement to NHS care. Previously, the rule had been that if a patient was having additional treatment in the private sector, they lost their NHS entitlements. This has become a cause celebre, especially in the case of some recently licensed cancer drugs.

At first glance this strategy might seem fairer – i.e no one should be denied NHS care. That is the heart of the meaning of what the national health service is – free, and available to all in need. Except of course, it’s not completely ‘free’ – many people pay prescription charges, or dental fees.

The reasons why I’m concerned are several. First, this is a green light for even more hype about new cancer drugs. I have not been convinced of either the wider media or even some researchers or doctors to present results of new research findings consisently in an unbiased way. I am afraid of the effects of overselling of benefits and the underselling of harms, or the lack of effect, to this group of patients and their friends and family.

Second, if a treatment is cost-effective, it should be available to all via the NHS. What makes something cost effective depends on how much we are willing to spend, and how much the intervention costs. The intervention may be too expensive for the limited benefit it provides. Or, of course, we could spend more on interventions, even less cost-effective ones, and there are expensive and ineffective white NHS elephants (Connecting for Health, PFI hospitals, Independent Treatment Sectors) which should be got rid of and the funds diverted usefully elsewhere.

But last, the other issue is that of the patient-doctor relationship. Fragmenting care into provision of some treatment in the private sector and the rest in the NHS is far from ideal. How will it be decided which are the ‘top-up’ private treatments and which are not (for example, follow up scans and blood tests which may be required as part of a treatment?) And how are patients going to feel if they are recommended to have a treatment which is too expensive to afford? Will they feel pressed to spend time, emotion and money on something which may not, in the end, be that useful to them?

In the wake of the subprime crisis and the stock market slide, counselling and psychotherapy services have been quick with offers of help for those dealing with the fall-out.

A generation or two ago, discussion of one’s personal problems was more commonly done in the public house, with a priest or parson, or with friends and family. This does not necessarily mean that it was ideal or even helpful. But is acquiring a professional ear for life’s troubles any better?

It would be quite normal to be upset by the loss of a much-loved job, or a lifetime’s savings. The question is whether professionally dispensed “therapy” would provide any greater comfort than one’s usual coping methods. Stressful events can act, in some people, as a trigger for anxiety or depression. But for those who are not ill, and who do not have a psychiatric disorder, indiscriminate use of therapy may actually do harm.

The remainder of the article can be read here. Please post comments below.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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