Defensive Medicine (work in progress)

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Defensive medicine is the medical branch of the Precautionary Principle. However, just like any other sphere of life, better safe than sorry is a platitude rather than a philosophy.Why?

Everything we do in medicine has a downside. Breast cancer screening, cervical smears all have a downside. One study published in the New England Journal of Medicine showed with ten screening checks a woman's chance of having a cancer scare was 1 in 2. This high false positive rate is partly down to defensive medicine.

The poltically motivated calls for screening ignore the practicalities of a screening programme. Screening is only justified if
1) the disease is fairly common and sufficiently serious
2) can be treated
3) the normal progress of the disease
4) the screening process will be acceptable in terms of cost and discomfort to subjects of screening
the cost is analysed as cost per life saved rather than cost per screening episode

There's no point in screening unless it has been proven that early treatment makes a difference. Earlier detection will automatically improve survival from point of diagnosis (lead time bias). There is still some controversy about breast screening. Some studies have suggested that a proportion of the cancers diagnosed and treated would not have progressed.

The more tests that are done the more meaningless results are likely to occur. The more people turn up to Casualty with the 'flu the more likely the overworked casualty SHO is to miss the case of early meningitis.

There comes a point when more medical input doesn't result in better health. Certain tumours picked up on routine scans are called "incidentalomas", because they are incidentally found and not harming the patient in any way. For example, a surgeon's wife had an adrenal tumour seen on ultrasound done for another reason. The standard practise if these tumours are not producing hormones is to observe them. Instead she had a complex procedure called laparoscopic adrenalectomy and the tumour was found to be benign. An unnecessary operation which could have had complications.

Current attitudes to the medical profession also affect the way the profession practises. In New York the publication of statistics for cardiothoracic surgeons made it more difficult for high-risk patients to get an operation. This trend has extended to this country where very sick patients who have a small chance of surviving with surgery, but none without, being turned down. These cases will adversely affect the surgeons' mortality figures too much. There was a case reported in the national press in recent years of a child turned down for cardiac surgery by Leicester's cardiothoarcic surgeons but accepted by Newcastle. The parents accused Leicester of giving up on their child. Damned if do, damned if you don't.

In the aftermath of the Bristol Inquiry further accusations of substandard practise were made against the country's premier cardiothoracic hospital, the Brompton. These were found to be groundless. This typifies the problem of case-mix - the difficult cases the Brompton takes on were bound to have a higher mortality than standard cases.

Here are some comments on messageboards as examples of criticisms of the medical profession and my comments:

I would strongly advise parents who decide to have their child immunised with the MMR vaccine to first request a health check. The parent should also request that the doctor sign a document confirming that the child is perfectly healthy in advance of the injection. If the medical profession, government and the Department of Health are totally convinced that there is no risk whatsoever to children then these reasonable requests should not be refused and would most certainly, in my view, give parents more confidence in MMR. Furthermore, any child adversely affected could be screened forthwith in an attempt to identify the cause and why they may have been susceptible to develop such a reaction. On behalf of the Bereaved Parents Action Group for Medical Accountability

Comment: This appears to be suggesting that doctors should give all children a full physical exam before giving MMR. Why? I can't see what this is supposed to achieve. A normal physical exam doesn't certify that a child or anyone is "perfectly healthy". The second point is "the medical profession, government and the Department of Health are totally convinced that there is no risk whatsoever to children", an impossibility with any drug.

If a member of your family was run over by a driver who was driving without due care and attention, would you just shrug your shoulders and say: "Oh well, to err is human." Yet how is that different to being permanently maimed by a surgeon? Or being damaged by being given the wrong drugs?

Comment: This person is arguing for criminalisation of medical errors. I use an analogy from an editorial in the British Medical Journal. An airline pilot does not fly his plane carelessly as if the plane crashes he will likely be killed. Yet plane crashes still occur. Therefore no matter what the consequences or punishments medical errors will still occur.

Whether you go down the legal route or the NHS official complaints procedure, the whole thing is a stitch-up from start to finish. Consultants involved in the error refer you to a friend for a 2nd opinion who covers up with a bogus diagnosis. You are blackballed by doctors which makes it hard to get remedial treatment. Your chances of legal redress are thwarted by greedy medical expert witnesses who write stupid reports that are full of lies. The lawyer silently pockets the Legal Aid money. The true victim is left high and dry without so much as a penny. There is NO access to justice. In the meantime, the errant doctors are not challenged, no lessons are learned, the same mistakes are made and systems are not improved. The truth is, patients are NOT protected in our current healthcare system.

Comment: This diatribe from a journalist suggests a conspiracy with far-reaching tentacles - no doctor I have spoken to has seen any trace of it (but then they're obviously part of the conspiracy). Amazingly the journalist's mother is a doctor - figure that one out!

I am diabetic and was put on the mini pill when 21 years old to help regulate problem periods. The pill I was put on should NOT have been prescribed to diabetics as it causes a form of tumour in the liver. This happened to me and I underwent major surgery 5 months ago. I currently work in the medical records section of my local strategic health authority, and when talking to my supervisor about changing GP practices as I no longer trusted my GP to correctly prescribe drugs for me, she advised that it is extremely hard to change GP practices without a good reason, as I would become "black listed" and branded a trouble maker. Before being given the pill, I was prescribed Tranexamic Acid - which is meant to make periods lighter by clotting the blood - again, this should not have been prescribed to me, a diabetic as the risk of break-away clotting is extremely high in diabetics. What I am trying to say, and I believe xxxxx is as well, is that although doctors are very good, they are GENERAL practitioners, not specialists, and as such know "generally" what to do, but not in infinite detail.

Comment: This sounds a dreadful case but looking at the prescribing details in the British National Formulary (the doctor's bible on drugs) there are no reasons given to not prescribe these drugs to diabetics. Where the poster has got this erroneous information from I don't know, but this is suggestive of pre-exisiting suspicion.

So am I just whinging or is there a point to this? My wish is that the public would appreciate that all doctors will make mistakes because they are human, but treatment doesn't always produce a good result even when no mistakes are made. The current climate does result in worse treatment for patients although superficially it may seem better. If statistics are to be collected they need to be the important figures correctly adjusted for caseload.

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