Guest post: "We must ask our doctors: 'is this treatment necessary?'"

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The other day, a colleague told me the following all too common story. A few weeks ago a 90 year-old woman was admitted to a local hospital with multiple problems. Not surprising perhaps for someone who has lived so long. One of these problems (though not the reason she was admitted) was having high levels of cholesterol, which as most people know, can lead to heart disease.

The guidelines, which we doctors are supposed to take into account at all times, say that one way to alleviate this problem is to prescribe statins. We know too that many people who are prescribed statins can experience an upset stomach or headache or feel sick for the first few weeks. That elderly lady died two weeks after the prescription from an unrelated disease, which was almost certainly going to kill her anyway. What really upset my colleague was that the last two weeks of her life were spent suffering from the side-effects of the statins, which the doctor had prescribed in absolute good faith and in absolute accordance with the training and the guidelines set out by the body that advises doctors on which intervention to make.

This story neatly illustrates the challenge we face in medicine every day: medicine, for all its high-tech advances in the last few decades, is not and will never be an exact science. No patient is ever the same, no symptom is ever identical and few treatments can ever be called perfect or entirely without risk. Most of all, medicine should be about people, and making decisions with them that are best for them. This is why my organisation, The Academy of Medical Royal Colleges, has launched an initiative called 'Choosing Wisely', which is about three things.

Firstly, we want doctors to understand that a pill, a test, or surgery – which by definition can be risky – may not always be the best solution for the patient. In my own field of psychiatry, we've long known that an episode of mild depression should be treated, in the first instance at least, with a prescription of some form of exercise the patient can do, often in conjunction with talking therapies. The problem is, most GPs aren't trained in psychiatry. How are they to define 'mild'? We know that anti-depressants aren't without risk, yet they continue to be doled out fairly easily, sometimes long after the episode of depression has passed, and studies reveal huge regional variations in the amounts of anti-depressants that are prescribed.

The second point is about patient expectation. Those people who are in and out of a doctor's surgery or their local A&E, convinced they have this or that illness and demanding a whole series of tests for them or their children, are not a myth. Our job is to manage their expectations or those of their parents. Of course we should commission the tests if in the clinician's view they are appropriate, but what we shouldn't be doing is ordering them just to put the patient's or parents' mind at rest. No healthcare system in the world has unlimited resources; our job is to be good stewards of the resources we have. Patients need to be more aware of the fact that one person having a test or treatment may remove the opportunity for other more pressing cases where the need may be greater or more genuine.

Finally, Choosing Wisely is about the doctor and patient having an open conversation together about what the risks and benefits are. It's about enfranchising patients and encouraging them to ask their doctor if this treatment or test really is necessary for them or their children. It may be that when they are fully informed they still want to go ahead. That's fine - we certainly don't want to ration treatments. But it may be that once they have all the information, they want a different option.

On this point there is some remarkable evidence: a recent study conducted into the use of stents, a common procedure used to widen narrowed or blocked arteries in the heart, showed that when patients were given basic information about the procedure, 69% were happy to have it carried out. But when patients were given full information about the likely impact and the extent to which a stent can remedy ongoing problems and extend life, just 46% of patients opted to go for the treatment.

Choosing Wisely will, I hope, help us to reach decisions together. Rational decisions based not on what we can do for the patient, but instead on what's best for the patient. And that's a decision we need to start taking together.

Molly, good suggestions, but that would be another 10 years or so of training, so not really realistic.

The defensive is a problem, but perceived attacks on the profession will not improve that IMO.
Tbh I do find it upsetting that there you say that drs as a rule 'despise patients' - not what I do nor what I have experienced at the receiving end of health care for myself and my family.

Pacific, because you are a GP yourself, you are not on the receiving end of the contempt which ordinary patients are accustomed to. And I'm not even working class any more.

Pacific, do you mean GPs would need 10 years' more training to become plastic surgeons, so that's why they can't leave, even though they would love to? So they are stuck in their miserable jobs which they hate?

Drs I see don't know I am medical unless I tell them - I work under my maiden name and am MrsPD privately, so I don't really buy that argument.

IMVHO it's not about 'anxious patients', it's about a frightened and worried society - a much wider problem. And medicine does not have the answer to that.

Again, coming back to the OP, part of the problem of inappropriate over treatment and over investigation is that of fear of litigation, fear of 'missing something' (which can of course always happen) and, lets face it, fear of death, fear of suffering. We are all dying, all of the time - and that is very hard to contemplate.
A lot of preventative medicine (controlling BP and cholesterol, encouraging health lifestyles) almost makes it seem that if you do everything 'right', you'll be forever young.
Also many an older person now very slowly dying of their, say, heart failure (when the heart muscle is no longer able to pump as strongly as it once did) are a success story of preventative medicine as they did not die of the heart attacks they had 30 years ago.

The problem is a complex one and I am aware I am not doing it justice, typing half-arsed, half-thought through comments while keeping DS2 company who is watching Planet of the Apes

Everyone knows you immediately get better treatment if you say your father (yes, it should be a male) is a consultant.

Not only that, but GPs I know are emboldened in dealing with their fellow medics because they know that, if it comes to it, they can pull that particular string. So they don't have the helpless feeling that non-medical people have in the face of hostility.

Springtime, that is awful

Well, I was referred to gyn, waiting 4 months to be seen, have now been waiting 3 months for a physic appointment.

There are huge issues of lack of joined up thinking - primary care and secondary care IT systems, for instance, don't talk to each other. When you see somebody OOH, they have v little access to your notes. Information flow of increasingly complex information is often rubbish.
It can take 2-3 months for us to receive hospital discharge letters or letters from clinics - why? Because there are not enough typists! Letter are dictated at the time of the clinic, but not typed until 8 weeks later, then transmitted electronically - oh the irony! In the days of snail mail and larger typing pools we actually got them quicker.

I meant to respond to Fanjo's link upthread about the pathetic lack of MH services - it is a scandal, an absolute disgrace. Even worse where services for children and young people are involved.

But never mind, lets give sound bites about 'everybody over 75 gets access within 24 hours' whether they are in actual need or not.

IME what people want is being listened to/being heard.
They want to understand their options.
They want to make informed choices.
They need timely and repeated access to support, particularly when the news was bad.
They want good communication.

All of that takes time and human resources and 'soft skills' which are not measurable in cholesterol levels. All of that is not very glamorous or exciting - I know it's what I valued when we feared for preemie DS2's life.

If I leave the profession prematurely, it will be because of appraisal and what it entails. I am sorry if you think that is pathetic, but it is the single aspect of my job that has driven me to tears of stress and rage. I take no issue with being appraised and I know it's been happening in many professions for a long time, but the unnecessary navel gazing and formalisation of what is an ongoing process anyway (there is no way you can be a dr without constantly learning and developing) and the time it is taking away from patients, family and, shock horror, time for myself I resent deeply.
BUT - it's introduction gave some kind of faux reassurance that the profession was being held in check or summat.
Shipman would've passed appraisal with flying colours btw...

And isn't cervical cancer screening fairly ineffective (and expensive)?

Yes, and there are better methods. But it's easy to count - the soft skill of how comfortable you make a woman when taking her smear, counts for diddly squat.

My recent PPH is a case in point of the argument here.

Admission to hospital with heavy bleed 3 weeks post birth - loads of examinations, scans etc. at one point asked doc 'what will repeating this scan tell you' response 'well, probably not much, but might as well do it again'. I declined the unnecessary repeat as it would make me uncomfortable and couldn't see the point. Antibiotics prescribed, sent home. The docs and nurses were all lovely but I did feel the environment was very 'intervention' (for want of a better word) heavy rather than just the basic observation which was probably all I needed.

Cut to GP surgery 4 weeks later. Asking whether my bleeding should still be this heavy (not as much as the massive bleed that took me to hospital) and what to look out for in terms of complications. She could not be less interested. When I asked what would cause her to refer me back to hospital for another scan she tutted! I hastily explained I didn't want one now but if I was still bleeding in another 4 weeks would that be a worry? Or was it only heaviness of bleed that mattered? She didn't really answer my questions just fobbed me off, told me to monitor the situation - how can I monitor something I've not been told the warning signals for?! - and made it very clear that unless I ended up back in gynae via an ambulance I wasn't getting another scan.

So - hospital doles out scans, GP very reluctant to refer. Now I know, I do know, the being in hospital means you are likely to be more ill than someone at a GP so the baseline for referring to a scan should be lower. But still I feel the massive disparity is wrong.

TL;DR I agree with OP re hospital treatment and PPs about GPs, from my experience.

Oh and can I just add that I'm sure the GPs posting on here are great GPs, and since like attracts like, probably work with great GPs. My old doctors surgery was lovely, brilliant, kind, helpful, explained things...then I moved :(
However as people on the politics threads are fond of saying, the beauty of mumsnet is it gives you exposure to people outside your usual circle.
There ARE bad GPs, and they do tend to congregate, so people who have experienced one bad GP at their practice are likely to end up with shocking care (like us) and therefore they shout loudly on forums like this. Because it's really, really horrible to have to put your trust in someone you know couldn't give a shiny shit about your worries, pain or quality of life.

The website Resilient GPs paints a shocking picture of doctors. If GPs are concerned about how they are perceived by the public - or indeed if they care a jot about their own professional standards - they should campaign to get that website taken down straight away.

I cannot tell you disheartening I find it that that is how you read the posts on that site, Molly.

A large amount of gp time is wasted by having to write letters to various council/government entities to prove that someone they hadn't even seen had been ill with an everyday virus.

We had issue with this when DS1 needed referral to ophthalmology. His paediatric consultant was no longer able to do this for us - as he said, it got stopped because certain government departments worried that consultants were referring g patients to their mates to keep them in business so to speak. He said we would have to waste a gp appointment to get them to refer DS. It took a fortnight to get this appointment, and I told the gp I felt bad for essentially wasting his time when the consultant should have been able to do the referral himself . It is yet another example of government policy making the job so much harder than it needs to be.

We sadly have a group of gp's in our area who refuse to refer a large number of people for DEXA (osteoporosis) scanning. They would prefer to just either treat or not based on computer assessment of risk factors. The scan costs £60. For that price you get a measure of bone density that try can use to either give lifestyle advice, or prescribe the right treatment. Then you repeat in 3 or so years to assess treatment efficacy. They don't want to do this, because it saves money (their words). How much money so they think it will save if these patients with undiagnosed osteoporosis fall and fracture a hip? Osteoporosis does have good outcomes if treated properly, and we should be scanning people who have the risk factors in order to prevent them getting so bad they wind up with fragility fractures, neer mind the morbidity associated with the elderly and hip fractures. All to save £60.

Fortunately we do have some excellent gp's who ignore this blanket decision made by some of their colleagues and I frequently suggest my patients see them. Obviously, this pushes their waiting lists up. There is no real easy answer, but more needs to be done to bring in more of the good, caring gp's who not only prescribe appropriately, but are capable of explaining to patients why they are embarking/not on a particular treatment regime, and give them the time to do so. I can't count the number if times I have been given prescriptions with no explanation of what it is or what it does. The best gp in our practice does, and it's no surprise he is always running late because he takes the time with his patients. It's very unfair to expect gps to have to feel like they need to turf people out of their room after a few minutes, when a number of them need more time and attention.

Sorry for the long ramble! I just feel the current system discourages the good, caring gps, and it's no wonder they retire early.

I have had a chronic illness develop during pregnancy which has now lasted 8+ years. No gp I have ever seen has ever been remotely interested in finding out why, I.e. what is the root cause.

As an outsider to this medical system (I am not British born but have citizenship and pay taxes, so yes actually I am allowed to use the nhs) my experience has been that you need to fight to get an appointment, and when you do, the gp is only half listening- here take these pills and get lost.

OP what is your registered profession
please?