Medical Journalism, and anti-depressants.

You have to love The Daily Mail. It's a better option than insanity, which, when faced with the fallout of its sensationalist reporting of most healthcare issues, is the only other option open to me. Love seems the sensible choice.

The British Medical Journal this week published this article about the rising incidence of anti-depressant prescribing by GPs in the UK over a period of several years. It's a good article - one that I hope many GPs will read and take to heart. In the study period (1993-2005) the number of new cases of depression remained fairly static, if anything dropping slightly, but the number or prescriptions for anti-depressants doubled. The conclusion (in the abstract) states:

 "The rise in antidepressant prescribing is mainly explained by small changes in the proportion of patients receiving long term treatment. Previous clinical guidelines have focused on antidepressant initiation and appropriate targeting of antidepressants. To address the costly rise in antidepressant prescribing, future research and guidance needs to concentrate on appropriate long term prescribing for depression and regular review of medication."

This sort of article would often lead to discsussion with colleagues about our review processes, perhaps an audit of our own figures, maybe an alteration in the advice we give when initiating a prescription and certainly an entry in our learning diaries for revalidation. All good science-driven medicine, with patient outcomes being directly altered by current research. 

However, the conclusion translates into The Daily Mail's preferred language, Fearspeak, as:

"Prescriptions for anti- depressants have soared despite fewer patients being diagnosed with depression, research shows.
It reveals the number of prescriptions issued by GPs for drugs including Prozac and Seroxat has more than doubled over the past 11 years.
And it warns the dramatic rise is largely down to more than two million patients taking antidepressants for years at a time  -  many of them young women."

Stricly speaking, of course, most of what the Mail has said is true. The difference is not in the facts that are being reported, but in the language used to report them. Prescription numbers haven't risen, they have "soared". The article states prescriptions "nearly doubled"; this translates into "more than doubled". "Small changes in the proportion of patients receiving long term treatment" becomes "the dramatic rise is largely down to more than two million patients taking anti-depressants for years at a time". While the BMJ article promotes a sober reflection on practice, and generates useful change, the Mail article generates such a fear of these medications in their users, many of whom, of course, already have pathological levels of anxiety as part of their illness, that the trust in one of the few useful tools that can help them is destroyed.

The Mail rightly points out that non-pharmaceutical therapies are recommended for the treatment of depression. It fails to note that access to those therapies in most areas of the UK is abysmal. It fails to note that the impact on the lifestyle of a patient of psychotherapy (an hour a week for weeks at a time) can make its use unfeasible, when compared to a simple tablet treatment. It fails to note that the lead in time to benefit is longer with psychotherapy when compared with SSRI treatment. These factors mean that when I prescribe anti-depressants, it is after a balanced discussion of the relative merits of all available treatments, and of no treatment at all. In fact, it is a patient's choice, made holistically, taking into account physical and social needs of the patient and based on a great deal more experience of a complex and misunderstood disease than most journalists could ever hope to get.

And yet, sometime this week, a patient will come into my office, clutching a clipping of this article, saying they want to stop their fluoxetine because they've read how dangerous it is in the Daily Mail.

And they wonder why it takes two and a half weeks to get an appointment with me.

Medical Tests

Sit down. Here’s some tissues. Here’s a cup of tea. Here’s a nurse. I’ve got some bad news for you. The NHS needs to get more expensive. Well, perhaps I should qualify that: clinical intervention within the NHS needs to get more expensive. You can probably more than make up the shortfall by cutting down on the ever-expanding cohort of managers whose numbers swell with every innovation so that it can be “properly monitored”, but that is another article. And you’re the customer, so I should explain why.

When you go to see your doctor, what is the first thing that happens? Stop and think for a moment… Do you immediately get a needle thrust into your arm for a blood test? Are your body cavities assaulted by a gloved hand? Do you even get a stethoscope on your chest? Hopefully not. Not straightaway, at least. The first thing that happens is that the doctor speaks to you. Even, in fact, if you are unconscious the first thing most medics are trained to do is to shake you by the shoulders and ask, “Are you alright?” It is an adage of medical education that, even with all the medical gadgetry at the disposal of the profession, 80% of the information that leads a doctor to make a diagnosis comes from the story you tell him. I believe this. Every week I see someone who has a pain in the chest, and they are worried that the pain is coming from their heart. Usually, just from their description of the pain, I can reassure them that some other cause is at the root of it. I may not be able to tell exactly what the source is so easily, of course, but the way your heart is wired into your nervous system produces a type of pain which is, well, just different to most other pains.

On many of these occasions this explanation is enough. Sometimes, however, a patient needs more than this. Most patients are aware of the electrocardiogram (ECG, or, for fans of American medical dramas, EKG); this is a reading of the electrical activity of your heart, and in its most basic form produces an A4 sheet with 12 slightly different wiggly lines on it. The various ways in which the lines wiggle can give your doctor very useful information about the condition of your heart. Interpreting ECG’s can seem rather like an art than a science. Students struggle with them, and they are taught the secrets of unlocking the information as a sorcerer’s apprentice might be taught to read the future in a crystal ball – that is, with great difficulty and through a fog of ignorance which is particularly keen not to clear. And in many cases, the similarity to crystal balls does not end there. Occasionally, when confronted with a patient with chest pain which is clearly not cardiac in origin, the initial explanation just doesn’t seem enough. Even though your doctor has known the pain is not arising from your heart from your second sentence, your worried eyes cast a glance at him just as your bottom lip curls into your teeth to be chewed. You’re wondering if it is impolite to ask, “Are you sure, Doctor?” when the doctor, ever keen to stay one intellectual step ahead of you (we are really a bunch of intellectual snobs who have to create a sense of superiority by translating your symptoms into Latin and pretending that’s a diagnosis) notices your disquiet and jumps in with, “But to be absolutely certain,” (for which read, “To show you I am never wrong”), “we’ll do an ECG”. Your face relaxes, and, as it does so, mine does too. I know I’ve won at this point, but the show is not over.

You see, now I can attach ten wires to your chest and limbs and, while we both watch, the wiggly lines draw themselves. It is like watching a seismograph in an earthquake. On older machines you could even see the little pen twitching away as your body’s activity was drawn magically into the paper. At this point, you are usually examining my face to see any signs of worry. I, on the other hand, am remaining strictly poker faced – the effect of the test relies on you thinking I am taking it seriously and, if I’m honest, I’m not sure how I would deal with an abnormality I wasn’t expecting; I can’t let you see that there might be one.

Then comes the examination: each of the twelve lines is examined thoroughly. The rate and rhythm of your heart are assessed. The morphology of the QRS complex is compared in the limb leads to the chest leads, and the corrected QT interval is calculated. This is where the sorcery is in medicine. Remember, I have known this ECG will be normal since long before I ever fired the machine up. But my experience wasn’t enough to reassure you, so this test must become the fortune teller. This test has to be seen to have the weight your reassurance deserves. And so I peer into it, as if waiting for the fog to clear, and gradually it does. I can see normality arising from the fog. I let a calm smile start to break out across my face and as you cross my palm with silver, I pronounce your heart healthy.

So what does that tell us? Well, several things, actually. Firstly that I actually do value your concerns and I’m willing to do things that maybe aren’t strictly necessary in a hard-nosed clinical sense to answer them. Secondly, and perhaps less wholesomely, I recognise that making my job look difficult makes you value me and my colleagues more. If you knew with the same level of confidence as me, that pointing to the pain with your finger (rather than using the flat of your hand) means it is not your heart, you would never have needed to come to see me in the first place. The mystique surrounding diagnosis has, since the very earliest days of medicine, been an important part of the diagnostic process. You need to believe I am very knowledgeable to trust me. I can increase that sense by making the knowledge look harder to grasp than it actually is. But by doing that, I have disempowered you from taking responsibility for your healthcare in areas where it is actually quite simple, and increased your subconscious reliance on the investigation process, while decreasing your opinion of my ability to work without tests being done.

So how does that mean it’s going to cost more? Well, for many years there has been great pride within the profession about what we call “clinical skills” – the ability to work effectively using as few tools as possible beyond the history of the problem and examining you. It’s quite right that we should improve these skills. There are times, particularly in General Practice, when access to investigations is very limited. Being able to continue to practise medicine in these situations has the same sense of satisfaction as Ray Mears gets by living in the jungle with as few tools as possible, and can be just as useful. The problem is that the sense of collective pride in clinical judgement has led to a situation in which it is considered very poor form to order a test and have the result come back as normal. The difficulty is amplified by the resource issue in the NHS; the rising pressure on radiology departments, for example (although the problem is not limited to radiology departments) has meant that there are increasingly strict guidelines forbidding such-and-such a test unless a particular set of circumstances exist. But I think we have gone a bit far.

Someone I know has recently developed a problem with their eye. One of the muscles that control the eye movements has stopped working. She sees double when looking in a particular direction, which is annoying. What is worrying is that she, being medical, knows that a sudden change in the function of one her nerves may mean she has a malignant tumour. The probability is low. Very low, in fact. But, let’s face it, when malignancy is a possibility the probability doesn’t have to be that high before you want reassurance, does it? So she did a bit of research and, based on her prior knowledge and Google, she thought that the likelihood was that she had had it for ages, but never noticed. “It’s an acquired Brown’s syndrome,” she told me. “When are you being scanned?” I asked.

Well, the answer that she had got from the ophthalmologists was that she had an acquired Brown’s syndrome and there is a very low probability of malignancy and there’s no need to scan unless you’re worried. Please, just humour me and read that last sentence again. Then compare it to what she already knew before she went in. Spot the difference? No, neither could I.

The bit which felt very uncomfortable was the “if you’re worried”. Now surely there is either malignancy there or not. It cannot be the case that malignancy is there if she’s worried and not if she’s not. And what about the other diagnoses it could be that are rare, but need intervention. It seemed to me, as I heard the story, that this was a case of relying on clinical skills too much and avoiding investigation in case the result was normal, and demerits were added to the clinician’s mental score for themselves. But then I thought, “What is the difference between this scan being done ‘if you’re worried’ and my ECG being done for the patient who is not reassured by my knowledge?” Well, the difference is this: the ECG was being done after the diagnosis of “Nothing serious”. The MRI was being declined while there was still a small possibility of serious disease. (In fact it was not being declined, but had been presented in a way that made the patient feel she was fussing over nothing if she asked for it – I’m not sure which is worse).

As clinicians, we need to be very careful about ordering tests. They are expensive. They are invasive. They are usually not without risk. They increase patients’ reliance on investigation, and decrease their trust in the doctor’s own skills. But, despite all this, sometimes they are necessary even though they’re not. Necessary for reassurance; necessary when the doctor-patient relationship needs a bit of illusion to make it work well; necessary, even, because the test would be expected by a lawyer if the notes were ever examined in court. It is fine to do tests in these circumstances, but they don’t need doing every time. On the other hand, there are some tests which seem unnecessary because the probability of finding something sinister is low. But these tests are always necessary; the illusion here is that it is alright to leave a few people to get advanced disease to save the many from… well, from what? In the case of MRI, not even from a small dose of radiation. The only thing being saved is the humiliation generated by received medical wisdom that a test which comes back normal is a wasted test. It is another example of the ways in which medicine is infused with institutional arrogance, and there is much more to write on that subject…

The Problem with Evidence-Based Medicine...

Today I have had to put yet another patient with mild osteoarthritis, a Mrs Smith (of course), onto an unnecessary prescription for non-steroidal anti-inflammatories. It’s not the first time. I’ve made a list of about 60 people who will be coming in at some point to have this same consultation. I’m only seen about 8 of them so far. Ah well, only 52 to go.

The reason these patients (and I am proud still to have patients, rather than clients, customers or prescribing units) are having to surf the wave of renal failure and gastric ulceration is that the Worcestershire Area Prescribing Committee don’t believe them when they say their pain is better when they take glucosamine. The PCT pharmaceutical advisors (who, I hope it’s not too creepy to say, usually do a great job) have looked at “the evidence”, have weighed it in the balance and found it wanting. Apparently glucosamine is no better than placebo at dealing with pain from osteoarthritis. We know that. The scientists have told us. So there.

The trouble is, I think they’re wrong.

Now before anyone tries to burn me at the stake for heresy, I would backtrack a little and say that I don’t think they are completely wrong. In fact, I think they have spoken the truth and nothing but the truth. But it isn’t the whole truth. I believe that when you look at whole populations of hundreds or thousands or people with mild osteoarthritis and give, fully blinded, half of them placebo and half of them glucosamine, there is not an appreciable difference in the outcome measures for each group. I believe that there will be a significant effect even in the placebo group, and that the mechanism of this effect is not fully understood. None of that is up for debate. I just don’t think that much of it is relevant to Mrs Smith.

The thing is, Mrs Smith isn’t a population of hundreds or thousands of people. Mrs Smith is a patient (there is that wonderful word again) with mild to moderate osteoarthritis. There are several important differences between individual patients and populations, and I don’t think the Area Prescribing Committee fully appreciate them.

Firstly, Mrs Smith’s choice isn’t: take glucosamine or take placebo. She has to choose between glucosamine and nothing. Now there has been a lot written about this argument, and I don’t intend to rehearse it here, except to say that glucosamine has few side effects, and even fewer serious ones. So by withdrawing what may be a placebo effect, we are forcing her to have pain or medication which is much more dangerous in the long run, both for her and for the purse string holders of the NHS.

Secondly (and again this is a common argument that has no need of review here) is that the placebo effect is a real effect. It has value. It has special value when the alternatives are much more dangerous. Furthermore, we can take advantage of it without duping Mrs Smith. We can be upfront about the fact that the effect she is having may be the placebo effect, relieving her pain through a complex pathway based in the biochemistry of the psyche rather than the spinal pain pathways. We can explain we don’t understand it fully. In short, we can explain that the label "psychology" is acceptable shorthand for "biochemistry we don't yet understand." And we can believe her if she tells us it’s working.

However, the most important difference between Mrs Smith and a thousand Mrs Smiths is the realisation that one is a model and the other is reality. There have been many occasions through my career when I have seen people mix up these two things, and Evidence Based Medicine has become the cause celebre of the mistake in recent years. Until EBM took the crown, the most obvious example was in teaching The Consultation through the famous models well known to any GP Training Scheme graduate. There we would be, on the video screen in front of our peers, sweat on our brow and palms dripping trying to make every consultation fit so-and-so’s model, in so doing completely missing the fact that the patient has already had a very satisfactory consultation thank-you-very-much, which has covered all ground it needs to and is complete without revisiting the patient’s dog’s birth history so we can tick the “holistic approach” box. We were making the classic mistake. In our minds the model had become the goal and if we didn't twist reality to fit the model, we had in some way failed.

It wasn’t until I thought about the linguistics of this that I finally understood it. The term “model” is not an accident. What is a model? It is a simplification of something complex, whose purpose is to aid the understanding of that complex entity by focussing the attention on just that part which is being studied. There is a great example of a model in the crypt of St Paul’s Cathedral. It is a wonderfully constructed replica of the entire cathedral made in dark wood, which has not been further coloured. It is usually surrounded by tourists who often find that looking at it helps them understand the proportions of the building (for instance, the way the dome relates to the lower sections) more easily than they could if they stood in the street and looked upwards. On the other hand it is a fair guess that it has never been surrounded by architecture students who wished to know the effect of the white light reflected from the marble façade on the brilliance of contrast of the decoration on the dome. It is, after all, made of wood and kept in a very dark room. So this model, this simplification, helps us understand one aspect of the reality at the expense of complete ignorance of another. All models do the same.

The reality of what goes on between a doctor and a patient is many times more complex than St Paul’s Cathedral, and yet both doctors and patients want to understand it. It is only by understanding it that it feels like a controllable and useful tool. And to aid our understanding or it, it has been modelled. A large part of the success of an interaction between a doctor and a patient comes from the medical knowledge of the doctor. That knowledge is gained from textbooks, journals, colleagues etc, but ultimately, where possible, from randomised controlled trials of treatments. These gold standard trials are spoken of in hushed tones when they are well designed and show an important causation, and there is a slight flinch of mistrust when one discovers that a particular piece of information came from anything less rigorous. They are so well regarded, in fact, that we seem to have forgotten what they were invented for.

And this is my heresy: that doctors, in our arrogance, believe that with enough study everything can be predicted and understood. We have forgotten that the randomised controlled trial is just a model of a much more important reality, and that reality is our individual patients, their illnesses and how we interact with them to seek improvement. I am not trying to take merit away from the RCT. It is still the best tool we have for trying to predict what is going to happen to a particular individual given a particular treatment. But like a craftsman working with tools which are wonderful constructions in themselves, we need to add the final tier of quality control, which is a critical inspection of the reality produced by those tools. It is that reality, after all, which will generate a response in the world.

And we need to do this quickly. We are living in a time when politicians and healthcare managers believe that medicine is a discipline which can be squeezed into protocols and delivered by… well, sometimes it feels as though they think it can be delivered by anyone who can read. At least part of the blame for this stems from the lie encouraged by EBM, that you can measure the outcome of a consultation by its performance against predictions from a statistical study. Until these priorities are returned to their original positions, then the balance between scientia and caritas will continue to be elusive, and Mrs Smith will continue to have to buy her glucosamine over the counter, or risk a stomach ulcer.