Tuesday, February 28, 2012

Doctoring health-care

Glasgow GP Dr Margaret McCartney is on a crusade against what she calls "sexed-up medicine".

The term, as she uses it in The Patient Paradox, her first book, covers everything from the oversold promise of preventative scans for cancer and "full-body MoTs" to charities pushing the cause of the week or pharmaceutical companies putting out misleading press releases.

It is political, too – given the argument she makes that some ailments are better treated as social problems than being viewed as medical. "We try to treat poverty with pills," she says. "You need to treat poverty with money." [alas, for SOYMB, our good doctor herself falls for another quack cure for poverty]

She explains "In the UK, social inequality is the biggest determinant of poor health and over-medicalising people is not going to help with that." The biggest area in which the health of Scots can be improved rapidly and effectively is by tackling those inequalities and preventing future ill health, Dr McCartney says. Instead, she argues, people are being put on drugs, such as statins (cholesterol--lowering tablets), including poor people deemed at higher risk because of their postcode or dietary factors. "Too often we are not looking at the real issues, offering a medical response to a social problem."

"I saw an advertisement urging people to have a CT body scan, with a patient saying 'I feel so healthy after it'," she explains. "Some are making a lot of money out of people's fears about their health."

GPs are paid for controlling risk factors, prompted by computer screens that remind them to do so. This can mean statins, smear tests and breast-screening or other scans.

For instance, most people on statins won't benefit, she points out. "For every 167 people we treat with statins, one will develop diabetes as a result. One in 60 people treated with it for five years will avoid a heart attack – 59 people who take the drug won't get that benefit. One in 268 will avoid a stroke – so 267 of them won't see that benefit."
While many people might think that finding a cancer, for instance, which can then be treated, is a self-evident good. But this ignores the risks of the test itself. Excessive scanning leads to people being treated because of "false positives", but also for problems picked up which would never have harmed them, she says. Breast scans are a classic example. "If 2000 women are screened for 10 years, one of them would avoid death from breast cancer, but we will also treat 10 women who were never going to be harmed."

The answer she proposes is not to stop smears, scans or prophylactic drugs, but to be more honest with patients about their limitations. However the system is skewed against such honesty.

She is also critical of charities, whose campaigns to raise awareness of a range of conditions can feed fear, and often depend on similarly hyped statistics. "It is understandable that they want their moment in the spotlight, but to get that people are having to sell their message in sexier and sexier style," Dr McCartney says. "The result is, for example, that young women asked by researchers about breast cancer overestimate their risk of getting it, while they underestimate the chance of successful treatment. A GP will see a woman who is terrified in case she gets breast cancer, but she may not be worried about her binge drinking or the fact that she's overweight."

The book contains the misleading press releases from drug companies which sex up a treatment's effectiveness by talking about relative risk ("it cuts your risk by 50%") rather than absolute risk ("it cuts it from two in 1000 to one in 1000").

What is good for a population may not be good for an individual, she points out. "Doctors have become de-professionalised so that we see patients as a list of indicators we have to satisfy...Most doctors will say they go into medicine because you feelthey have a vocation. By the time they come out of training that has been almost dismissed, and they are given a computer programme and a set of targets. I'd like us to re-professionalise"

SOYMB cannot provide the blueprint for the socialist health services but we can be sure that the debate and issues raised by this one working GP will be added to by the contributions of tens of thousands of doctors, nurses and medical workers leading to our approach towards health transformed.

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