ay, I've had a lie down so I'll try and sift through some concerns, I hope it's helpful, please feel free to agree or disagree, or if there are any epidemiologists/public health/experts in the fields of critical appraisal, please feel free to chip in.
The following is my opinion, and any individual medical advice should be backed up by your doctor and medical authority.
I've retired from The NHS but do still see patients. I've been proud to be part of three main achievements that I've observed over the last 30 years:
-Cancer is now classed as a "chronic disease" (We've got a long way to go.)
-We now afford dying patients the care they deserve (We've got a long way to go.)
-People my age aren't dying, or becoming irreversibly damaged by the effects of atheroma-furring up of the arteries (We've got a long way to go.)
I trained in Manchester, if you think of "Joe Average" chances of dying early through heart disease as equaling 100, then some parts of my ward scored 176. (SMR rates).
I have total respect for Pace and those others who have posted on here, exacerbated by the fact that we seem perhaps a little too eager to commit them to a lifetime of medicating.
I'll try and sift through things as best I can.
Firstly, the "cure" thing. I can't remember the last time I cured someone.
My surgical colleagues may disagree with me, but let's face it, one of the major reasons cancer patients have better surviveability is because the surgeon now talks to the radiologist, who now talks to the oncologist etc etc.
I think it may have been when I syringed someones ears in the nineties- they stopped us doing that, as someone worked out that the "risk/benefit" equation demonstrated that we burst more eardrums from the silver thing that flew off the end on the syringe, than the inconvenience we would cause by saying to the patient "put olive oil in your lug hole until the wax falls out."
How we define "health" is riddled with problems. I've dealt with 18 year old patients, who, on the face of it, appear healthy to me. Correct BMI, "normal" blood pressure, low cholesterol etc etc, - the fact that he can't face going to work in the morning, makes him, in his eyes, unhealthy. Conversely, there's a girl who works down our local ASDA on the tills, who was obviously born with the most terrible congenital abnormalities. She daily serves me with my crate of Pinot and Rustlers burgers. She always looks happy, and smiles all the time. I'd love to ask her if she feels healthy.
Medicine seems fascinated by "The Absence of Disease but I suspect that there is more to this than meets the eye. We sometimes don't seek to promote positive health, and sometimes we tend to overlook the wider determinants of health.
The evidence bit. Heart disease and stroke kills and maims hundreds of thousands of people in the UK each year.
I'm not that arrogant to state that medicine makes that much difference. Pound for pound, spending money on pre-school education and town planning can probably do more than anything I can write on my prescription pad. Getting my patients to walk 30 minutes a day for 4-5 days a day is far more effective than any pill I can prescribe.
Medication, actually, is only a part of the solution.
I think what we are talking about here on this thread is primary prevention, which essentially involves asking someone to take a chemical for the rest of their life-when they are actually well. They won't feel any better for taking this chemical, but they may actually have adverse effects.
It's a hard sell.
I think it's a fair comment to say we have been influenced by external factors that haven't always served the best interests of the patients.
I, like Radgirl have not had a "free lunch" from a drug company rep for a very long time.
I wouldn't dare :-)
There are checks and balances in the system, a sort of "division of the powers" involving the statutory bodies such as NICE, the local regulators, Medicines Management as well as our own accountability to our employer, civil law, criminal law, etc.
In terms of how we do it?
Secondary prevention (treating people who already have established disease) is a no brainer and actually causes us (prescribers) no hassle-a touch near to death is a great concordance motivator.
Primary prevention is a bit more tricky, and it's a "hard sell."
In terms of evidence, we try to stratify things in terms of "robustness."
At the bottom of the pile
anecdotal evidence.........not always to be discounted, I'll even give some of my anecdotal evidence later.
In the middle
are cohort/population studies. (Let's see what happens to a hundred patients in Iceland who eat a lot of Fish compared to a hundred patients in Salford who eat MacDonalds.)
At the top of the evidence pile are the Multi-centred, Blind, Randomised Control Trials (Have a look at The BMJ)
It's this sort of stuff that our prescribing decisions are (or should) be based upon. We don't always achieve this (SSRi's anyone?)
The decision to treat is based on some sort of risk assessment (don't shoot the messenger.)
This usually involves placing certain variables into an algorithm, (blood pressure/HDL/LDL/postcode (!), smoking status which then gives us a "ten year" risk figure.
The "ten year risk" figure is quite crap.
It tells me how many "People sat in front of me with this blood pressure/HDL etc etc) are likely to have an arteriosclerotic event in the next ten years.
What it fails to do, is tell me which patients, out of the theoretical hundred, will have an event, and which won't.
I use a 10 by 10 grid to sort of play odds management with my patients.
This is the most important point-statins only work if patients take them daily, from this thread, it sounds like many aren't. Communicating the facts is key, but at the end of the day, patient choice is paramount
In terms of doing good and doing harm, I can only report anecdotal findings.
Myalgia (muscle pain) is quite common, the key here is education, any muscle pains should be followed up with Blood Tests, to exclude Myopathy (Muscle Damage), I've seen a couple of cases of deranged liver function tests, both of which resolved on titrating the dose down.
The key here is to attend for the initial blood tests.
I walk round Manchester now and very rarely see IHD/CVA crippled people :-)
Last edited by gingernut; 4th Oct 2015 at 14:01.