Mass medicalisation is an iatrogenic catastrophe

by James Le Fanu. BMJ 2018;361:k2794 (June 28, 2018)

Profligate prescribing has brought a hidden epidemic of side effects and no benefit to most individuals.  [All of us who drift into physicians’ offices are subject to over-medicalization by overworked, ignorant, well-meaning, but  often autocratic, physicians. DJE]

Excerpts:

“Tis impossible to separate the chance of good from the risk of ill,” wrote David Hume presciently, anticipating, by 250 years, medicine’s current existential crisis. There is no drug or procedure with its “chance of good” that may not harm some. The more doctors do, the greater that risk. And doctors are certainly doing much more with, over the past 20 years, a dizzying fourfold rise in prescriptions for diabetes treatments, sevenfold for anti-hypertensives, and 20-fold for the cholesterol lowering statins.

There is a hidden epidemic of anxiety-producing symptoms such as fatigue,

muscular aches and pains, insomnia, and general decrepitude, a 75% rise in emergency admissions to hospital for adverse drug reactions.  Le Fanu feels that this was driven by sophistic public health research that played into the drug industry’s goal of mass medicalisation.

This ‘close alignment of the priorities of public health with the marketing practices of this most profitable of industries’ has been achieved by lowering the threshold for initiating treatment to include those whose physiological variables are only marginally elevated, if at all. The simple expedient of redefining diabetes, hypertension, and hypocholesteraemia in this way increased their prevalence in the US by, respectively, 14%, 35%, and 86% -- an additional 56 million cases, more than a third of the total adult population of 187 million.

The population was not “sick” after all, but has certainly been made sick by the iatrogenic consequences of that profligate prescribing.

How to Fix the Premed Curriculum

Lewis Thomas,  New England Journal of Medicine, May 25, 1978

(This was written 40 years ago, and nothing has changed!)

PDF of How to Fix the Premedical Curriculum

  

Notes on article.
The influence of the modern medical school on liberal arts education in this country over the last decade has been baleful and malign, nothing less. The admission policies of the medical schools are at the root of the trouble. If something is not done quickly to change these policies all the joy of going to college will have been destroyed, not just for the growing majority of undergraduates who draw breath only to become doctors, but for everyone else, all the students and all the faculty as well.

Thomas states that the rhetoric of medical school catalogues is to major in non-science discipline as history, English and philosophy; even so, not many do. Pre-medical students didn't buy that line. [In 1978 they continued to concentrate on science. I don't see much difference today.]

The pre-medical students concentrate on science with a fury, and they live for grades. If there are courses in the humanities that can be taken without risk to class standing they will lineup for them, but they will not get into anything tough excepting science. The atmosphere of the liberal-arts college is being poisoned by pre-medical students. This is not the fault of the students. They behave as they do in the firm belief that if they behaved in any other way they won't get into a medical school.

Thomas suggests that any college maintaining offices for people called pre-medical advisers should be excluded from recognition by the medical schools.

Knowledge of literature and language ought to be the major test and the scariest. History should be tested with a rigor. Students should know that if they take summer work as volunteers in their local community hospitals, as ward aids or laboratory assistance, this activity will not necessarily be held against them, but neither will it help.

The first and most obvious beneficiaries of this new policy would be the college students themselves.  Society would be the ultimate beneficiary. We could then look forward to a generation of doctors who have learned as much as anyone can learn, in our colleges and universities, about how human beings have always lived out their lives.

Levels of racism: a theoretic framework and a gardener's tale.

by Camara Phyllis Jones

Am J Public Health. 2000 August; 90(8): 1212–1215.

Note:This is one of the key articles on racism in health care and in our society.

Abstract: The  author  presents  a  theoretic framework for understanding racism on 3 levels: institutionalized, personally mediated, and internalized. This framework is useful  for  raising  new  hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences.

She then presents an allegory about a gardener with 2 flower boxes, rich and

poor soil, and red and pink flowers. This allegory illustrates the relationship between the 3 levels of racism and may guide our thinking about how to intervene to mitigate the impacts of racism on health. It may also serve as a tool for starting  a  national  conversation  on racism.Link to Free Full Text.

Osler's Bedside Library Revisited

Osler's bedside library revisited—books for the 21st century: Personal Views

Sanjay A Pai and Roop D Gursahani. BMJ. 2005 Dec 17; 331(7530): 1482.

Free Full Text. (scroll down to page 4)

Medical education is, in many ways, incomplete. Although we are taught about the science of medicine, most medical school curriculums lack formal teaching on the humanity of medicine. Ethics, history, and philosophy are not taught formally in many schools. William Osler was one of the earliest to realise this, and in 1904 he proposed a bedside library for medical students. 

This is a thoughtful article that is worth reading.  Free Full Text. (scroll down to page 4)

Image from the BMJ article

Heartsink Patients

Heartsink" patients exasperate, defeat, and overwhelm their doctors by their behaviour. A group of such patients was followed up over five years in a general practice, and this paper describes what happened to them. As a group they were often in employment and in stable relationships, though women were over represented. Half the group were subjected to a management plan which seemed to make them less heartsink over the five year period. While heartsink patients often have serious medical problems, they are a disparate group of individuals whose only common thread seems to be the distress they cause their doctor and the practice. Heartsink as a phenomenon has features that are unique to general practice.

T. C. O'Dowd. Five years of heartsink patients in general practice. BMJ. 1988 Aug 20; 297(6647): 528–530.  Free Full Text.

[This is an important article.  We all see these patients.  Some of us groan when we see them on the daily list.  Others may look forward to the challenge.  Heartsink patients may be those who are stuck in a chaos story.  They are not questing and have not achieved restitution (see  Frank, AW.  The Wounded Storyteller).

Death is no longer just in the hands of god or fate, but often a decision

"On 30 October 2017 I had just landed at Heathrow from Melbourne. I had the strangest feeling I should not go directly to bed. I wondered if I should visit my mother, Margaret Black, a 92 year old retired anaesthetist living very independently in a warden assisted housing complex in Kent. At midday I got a call from my sister—mum had developed abdominal pain, pressed the alarm button, and phoned her GP. Could I go?

There is much discussion about the right of an individual to die, but not enough about the role of relatives and friends"  Dr. Black's essay is powerfully resonant with our lives.

Black ME. Death is no longer just in the hands of god or fate, but often a decision.  BMJ. 2018 May 22;361:k2217.

Full BMJ article