Questions about healthcare

The first time I heard about neuro-linguistic programming, I was intrigued. By scrutinising and changing a person’s speech and body language, NLP promises to improve social and professional interactions.

It has, we’re told, the power to “unlock your capabilities”. Negative psychological patterns are identified, and can be “reprogrammed”. Sensitivity to others’ behaviour is also heightened. Indeed, by showing me how to “read” unconscious behavioural signs, it could allegedly help me be a better doctor.

The technique has been around since the 1970s. Its methods have been described enthusiastically in publications as respectable as the British Medical Journal, while the Royal College of General Practitioners is running NLP “master classes”. The course blurb says: “Neuro-linguistic Programming is the study of human excellence, in terms of how we can learn to take control of our consciousness … We know that an optimistic outlook and good emotional management improve health so it is important to teach others (and ourselves) how to change limiting beliefs and attitudes to restore health and maintain happiness.”

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

Exercise is good for you. This is the gospel that we doctors are enjoined to preach to patients – we even have prescription pads to refer people to the gym.

But there is a snag: the more you exercise, the more likely you are to pick up a sports-related injury. We are taught from an early age that warm-ups and cool-downs are the best way to prevent this, but it is not entirely clear whether either routine does us any good.

The science supporting the notion is far from robust. A review of the evidence published last year by the international, not-for-profit Cochrane Collaboration suggested that warm-ups did not prevent injury or muscle soreness after exercise, while cool-downs did not prevent post-exercise pain either. 

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

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.

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.”

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.  

It was reported today that East Lancashire Primary Care Trust have a plan to deal with overweight schoolchildren. When the children return to school after the summer holidays they are to be weighed, and, if overweight, apparently they and their families will be ‘cold-called’ by nurses, who will then encourage them to lose weight.

But how? I’m sure the intentions behind this scheme are good ones. But I can’ t help wondering how evidence based this scheme is. The Cochrane Library contains information about  interventions for reducing obesity. Essentially “there is a limited amount of quality data on the effects of programs to treat childhood obesity”. In terms of prevention, another Cochrane review says that “There is not enough evidence from trials to prove that any one particular programme can prevent obesity in children, although comprehensive strategies to address dietary and physical activity change, together with psycho-social support and environmental change may help”.

My concern is not just that I loathe pushing unsolicited medical advice. It is also that all medical interventions contain the possibility of harm. We don’t know whether children will be stigmatised or totally turned off by this kind of intervention. Additionally, the resources may be better used elsewhere to pay for decent and exciting play parks (I am always sad when the tiny patch of grass in housing estates is marked with ‘no ball games’ signs), safe road crossings to walk to school, or free good quality school lunches for all. But without considering what the evidence tells us, and trying to address these and their multiple uncertantites, we are not going to be doing anyone any favours.

Sex sells. I suppose this is why the results of a study entitled ”Sildenafil Treatment of Women with Antidepressant Associated Sexual Dysfunction” were reported with great enthusiasm around the world after they were published in the Journal of the American Medical Association (Jama). Yet the study is interesting for a number of reasons.

Rest of column here.

The National Institute for Clinical Excellence is proposing that four drugs licensed for the treatment of renal cancer are not to be funded; they are not, we are told, ‘cost effective’. Charities, doctors groups and patients are reported today as condemning the situation with strong criticism of NICE. However, there are surely other criticisms due. If the pharmaceutical companies manufacturing these drugs wanted to make them ‘cost effective’ then they could reduce the cost until they are.

One of the medical newspapers, Pulse, has a news article saying that there has been a drop in the number of  homeopathic prescriptions by GPs in the UK. In 2005, there were 83,000 written, and in 2007, it had fallen to 49,300.

This is good news. It could be that GPs are becoming more critical about the evidence for their prescriptions, or patients are being more critical of the evidence for what works. One UK NHS homeopathic hospital has had funding withdrawn. The National Institute for Clinical Excellence evaluates interventions and recommends that treatments of marginal or no cost effective benefit are not funded. However it is most unfair that homeopathy, which the evidence says doesn’t work beyond that of placebo, has yet to undergo a similar evaluation.

Having said that, homeopathy does have a placebo effect,  a valuable thing. The placebo effect could be regarded more broadly as the beneficial effects of medicine which are not mediated by a biologically active ‘medical’ intervention itself – placebo pills and even placebo surgery have been found to have beneficial effects for patients. So have, for example, continuity of care, and longer appointment times. The ethics of using placebos are fraught. However, there is no such ethical problem with providing longer appointments and continuous care. It seems most unfair that the  people currently allowed to benefit most from the placebo effect are those who are prepared to use homeopathy. There are other, better things that could be used for more people to benefit from such ‘caring effects’.

Ever more medical tests are becoming must-haves. Now the glomeruli, the hardworking but scarcely acknowledged filters of the kidney, are at last to have their 15 minutes of fame.

Taiwanese researchers, reporting recently in the Lancet, say we should all know how well ours are performing. However, the blood test to establish the “glomerular filtration rate” (GFR) is not as straightforward as we might like to think. By looking at glomerular filtration rates over 12 years, the researchers in Taiwan found a link between a low GFR and an increased mortality rate. Because of this, they suggested that the GFR test should be promoted to the public

/…full column here

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.