The Naked Doctor: an indepth look at the pitfalls of “cutting edge” medicine
The Naked Doctor is an ongoing project at Croakey that aims to encourage discussion and awareness of the opportunities to do more for health by doing less.
In this latest edition, Dr Justin Coleman suggests that an equitable health system does not mean trying to give everyone the very best, if that means “the most tests, the most expense, the most treatments”.
“Not only will that aspiration require others to miss out on even the second-best treatment, but it too often also actively harms the recipient,” he says.
Perhaps one area where more intervention is needed is in tackling overdiagnosis and overtreatment – Dr Coleman suggests that if the ‘medical market’ is left unchecked, the balance naturally tips towards overtreatment.
He concludes with a powerful call to action:
“As a GP, I am a gatekeeper to a most powerful, expensive, superb and dangerous health system and I must never forget that sometimes my job is to shut the gate.”
The article below is based upon his plenary address to the Qld RACGP Annual Clinical Update in Brisbane last month.
It is dedicated to the late Professor Gavin Mooney, whose philosophy was that we must “judiciously apply what we know works, rather than enthusiastically embrace what we wish would work”.
The ethical imperative to tackle overdiagnosis and overtreatment
Justin Coleman writes:
Two years ago my good friend Gavin Mooney gave me a signed copy of his latest—and, as it turned out—last book, Evidence-Based Medicine in its Place.
Professor of Health Economics at Curtin University, Gavin was an irascible Scot, and his book detailed his work with another great Scotsman, Archie Cochrane,who of course pioneered the science of Evidence-Based Medicine.
According to Mooney, after their first meeting, Cochrane informed him that he had revised his opinion of economists.
On the basis of the evidence of an afternoon with Mooney, he now placed them second bottom, with sociologists at the bottom. This merely confirmed for Mooney that there was much on which they agreed.
Mooney told me the story, repeated in his book, of how Archie Cochrane first gained notoriety as a very junior staff member at the massive Department of Health in London.
The young Archie presented slides from an RCT on outcomes after heart attacks following rehabilitation, either while remaining a hospital inpatient or after early discharge home.
London’s ‘Who’s Who’ of learned physicians nodded sagely as Archie showed the crucial slides where the hospital outcomes—represented in red—outdid the blue columns of home-based outcomes across nearly every parameter. A couple of supportive comments, no questions.
Then the young epidemiologist pretended to look flustered. ‘I’m terribly sorry. I seem to have mixed up the red and the blue!’
He had deliberately switched the labels. All the better outcomes were in fact in the home-based, early discharge group.
Needless to say, chaos ensued as suddenly a hundred disgruntled audience members grilled him on every possible dubious aspect of the study design!
Best practice or common practice?
Until that time, there had been no reason for a London physician to doubt that an intensive, expensive, high-tech hospital stay would improve health outcomes.
It made perfect sense, and a whole bunch of highly intelligent, caring physicians had spent their careers ensuring that such a system existed. Where it wasn’t affordable, public and charity funds were sought to ensure more people could get longer hospital stays.
This was best-practice care, in the same way that bed rest for back pain, monthly breast self-examinations, and antibiotics for sore throats have been understood by clever and well-meaning people to be fairly obvious best care. More about Archie—and Gavin—later.
In the brilliant Mitchell and Webb parody of a Homeopathic Emergency Department, Webb attempts to save a trauma victim’s life by drawing on his palm in pen to extend his life line. He justifies it by asking ‘Have you got a better idea?’
Luckily, the answer is ‘yes’.
There are some things that do work better than a pen mark, or a homeopathic vial of water, even a vial where the water molecules somehow retain the memory of a herb they once knew, while conveniently forgetting they were once flushed down a toilet.
And there are some things that do work better than our mainstream medical interventions, even when tens of thousands of medical practitioners believe they are doing the right thing.
This has always been true, and will ever be so. Our mistakes from the past remind us that we are making mistakes right now. Full credit to all those anonymous doctors and researchers who unwrapped these anomalies.
The art of discovering nothing
History rightly lauds those who discovered ‘something’; Alexander Fleming and penicillin.
But I also dips me lid to those who discovered ‘nothing’. Bloodletting doesn’t work. Arsenic doesn’t work. Keeping kids with polio in hospital back straighteners for six months of their lives doesn’t work.
In many cases, our patients would be better off if we chose not to act.
There’s a minimum standard in the medical profession—not the gold standard, but let’s call it the bronze.
The bronze standard is that the patient is no worse off as a result of seeing us. The bronze standard is probably achieved by enthusiasts who light ear candles and discover people’s chakras. Let’s at least stop doing things which fall below the bronze standard.
We must balance the important and exciting work of discovering new stuff with the un-sexy hard-slog science of analysing those times where we have over-reached and over-enthused.
The best of our medical predecessors started this process and we must continue it; this is why we are a science and not merely a tradition.
Two hundred years ago, the French physician Phillipe Pinel cared enough about the damage his colleagues were doing to his psychiatric patients to observe:
“It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.”
It took a young epidemiologist Archie Cochrane to highlight the flaws in obstetric practice that should ideally have already been obvious to the world’s leading obstetricians and their institutions.
And these were not minor flaws. Obstetrics units in one part of the world were teaching methods which had already been shown in another part of the world to kill women and babies, and vice versa.
Cochrane didn’t do the research himself; his genius was to inspire others—in this case, Iain Chalmers— to collect, collate and analyse all the available evidence and, importantly, reject the shoddy stuff: the anecdote and the meaningless trial, so that obstetricians and their departments could make informed decisions as to how to get the best outcomes.