‘We overtreat the well and undertreat the sick.’ This ‘Patient Paradox’ is a result of sexed up medicine, in which pharmaceutical companies, health charities, commercial screening companies, successive governments and even the NHS are complicit. That’s the verdict of author, Margaret McCartney, a Glasgow GP.
‘That’s the paradox that I keep finding within the NHS: if you are ill, you may have to be persistent and determined to get help….Yet if you are well, you are at risk of being checked and screened into patienthood, given preventative medication for something you’ll never get, or treated for something you haven’t got.’
Dr McCartney has significant concerns about large scale screening programmes for people who are well. She recognises that the idea of screening to prevent illness is seductive. However, having reviewed a wide range of evidence her verdict is this: ‘A perfect screening test would be one that was always right, neither invasive nor unpleasant, with a cure that was always successful and with no side effects. Welcome to la-la- land. There is no such thing as a perfect screening test.’
She looks in particular at screening for breast cancer, cervical cancer, prostate cancer and bowel cancer; and at cardiovascular risk and the use of statins in people who are otherwise well. Here are some of her findings:
- ‘If 2,000 people are screened regularly for ten years, one will benefit from screening, as she will avoid dying from breast cancer. At the same time, 10 healthy women will, as a consequence, become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or their whole breast removed, and they will often receive radiotherapy and sometimes chemotherapy.’ (Nordic Cochrane Centre, Denmark)
- ‘It’s not good being told that your risk of death (due to cardiovascular disease) can fall by 12% if you take a statin (the relative risk) when the figure is really only 1% (the absolute risk) (and) the side effects of statins make up a long list.’ (based on meta-analysis in The Lancet in 2005)
- ‘The test (PSA test for prostate cancer) is hardly more effective than a coin toss…PSA testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer – the one that will kill you and the one that won’t.’ (Richard Albin, originator of the PSA test)
Dr McCartney distinguishes between screening people who are well (which is what she is concerned about) and diagnosing and treating someone who has symptoms (which is what she wants to give priority to). She notes that it can be possible to live with a range of apparently harmful illnesses (from cancer to brain aneurysms). These are sometimes fatal, sometimes not. So screening for them, she argues, means we may be treated for something that wouldn’t kill us, where the treatment itself may be invasive and have potentially harmful consequences or side effects.
The argument here is probably strongest where Dr McCartney shows potentially serious health consequences, like the pancreatitis arising from surgery suffered by a former Canadian Prime Minister when his CT scan showed a false positive – or the small but real risk (1 in 14,000 according to the NHS) of fatal breast cancer caused by exposure to radiation during breast cancer screening. The argument is probably less strong when the harmful consequences are seen as primarily anxiety arising from false positives.
Dr McCartney doesn’t seem to be arguing that screening would never be justified. However, she makes an impressive case for patients, doctors and policy makers thoroughly checking all the evidence first and not assuming screening is intrinsically beneficial.
Screening people who are well isn’t her only target. Dr McCartney also questions the value of vitamin supplements and of protocol based health advice lines (like NHS Direct). She questions the influence of pharmaceutical companies, of interventions from sound bite politicians and of single issue interventions by health charities. She also questions the GP contract (which she argues distracts GPs from listening to their patients, through the computer generated reminder questions to meet contract targets).
One piece of good news is that Dr McCartney has a simple prescription for reducing the risk of premature death and increasing the number of good quality years. It is very similar to the information we provide here on Age Watch. She says, ‘For free, don’t smoke. Don’t drink excessively, and not every day. Eat a wide variety of foods, mainly fruit and vegetables. Exercise daily, and if you can make it social. Have a job you like. See people and do things you enjoy. Stay reasonably trim. And don’t be poor.’
She sees this last point as particularly important, quoting research from Sir Michael Marmot, a leading public health doctor. He identified the main factors leading to early death internationally as being social gradient, stress, poor circumstances in early life, social exclusion, work, unemployment, social support, addiction, food and transport problems. This leads her to ask, ‘ Is it right to treat the outcomes of poverty with medicine, when the real sources of preventable diseases are social and political? ’and to argue, ‘Addressing inequalities is where the biggest gains in healthcare are to be made.’
Part of Dr McCartney’s prescription is to remove what she sees as the obstacles to a good doctor patient relationship and to move doctors and their professional judgement and care back to centre stage, including at the end of life – observing, ‘District nurses and GPs have been moved from the epicentre to the periphery. Dying people must now rely on the generosity of strangers to fund overnight nursing care at home, or a place in a hospice.’
At times Dr McCartney presents a somewhat idealised view of the medical profession and the doctor patient relationship. There are many excellent doctors but the reality is probably more mixed, as we know from a number of GMC Fitness to Practice cases and, at a more basic level, nearly 30,000 patient complaints about clinicians in GP Practices in the past year (according to the NHS Information Centre). Another example is that she describes the retreat from 24 hour care by GPs as being due to the financial gain of doing out of hours being marginal, suggesting that GPs’ professionalism may not always be quite as resilient as Dr McCartney might wish.
One of the strengths of this book is that it is strongly evidence based , drawing on and referencing over five hundred sources of evidence, many from peer reviewed scientific journals. For non medical readers there is also a useful glossary, explaining a range of terms used in the book, from absolute risk to systematic review.
A possible disadvantage is that it isn’t always clear who the target audience is. The general public are likely to be interested in aspects such as the pros and cons of screening but may find the volume of statistics and references sometimes hard work – and not clear what specifically they can do to make a difference. Doctors may respond positively to the message that the doctor patient relationship should be central, rather than a doctor customer relationship – but may not be happy with the examples she gives of doctors sometimes being complicit in the changes she complains of. Policy makers are arguably the ones who most need to consider what Dr McCartney is saying but her critical approach to health policy making in recent years may not endear her to the people she needs to influence here.
Overall though, whether you want to explore the pros and cons of health screening or some of the major issues facing healthcare in the UK, this is a book well worth reading. It is persuasively argued and evidenced. It addresses health issues that matter to us all. At times it is controversial and challenging – but throughout Dr McCartney’s own desire to help those who most need healthcare shines through.
The Patient Paradox: Margaret McCartney (Pinter & Martin 2012, ISBN 978 – 1 – 78066 – 000 – 4)