For what is in the light....

Disclaimer: This post is not anti-establishment or anti-authority in any way. It merely reflects the author's views and personal journey of discovery. He may not know enough or know any better, preferring those who read to form their own conclusions. Also, non-medics are advised not to read this unless they want to be extremely bored.


This post will probably make sense more to the medics, but I posted it because its a sort of revelation to me how things happen behind the scenes in the 'system' in the UK. Recently the small surgery in the community I go to brought up some interesting issues. Most of the GP visits have been good fun so far, with my only regret being I wasn't at another practice when a certain celebrity visited.

Anyway, my GP asked me to look up results of a trial called ASCOT, which basically compares medicines for treating high blood pressure, which is pretty common in the community. The results of this trial was supposed to be groundbreaking(jargon coming up). Results showed ACE inhibitors and calcium channel blockers were more effective in the treatment of hypertension (high BP) than the traditional treatment of beta blockers and diuretics. Being a typical student who doesn't look up trials and journals for 'self-development' often, I had no idea where to look. What I did find out, was interesting though. To cut a long story short:

- ASCOT was considered so groundbreaking it influenced the British Hypertension Society and NICE (National Institue of Health and Clinical Excellence) to change their guidelines.

- Soon the entire country will experience a change in the drugs given to treat hypertension due to the change in guidelines mentioned above.

- However an increasing number of doctors are concerned about the validity of ASCOT, as large and as effective as it sounds.

- A search of letters in BMJ showed doctors from all over the country writing in to say:
- ASCOT's primary outcome was statistically insignificant and most of its successes were in
achieving its secondary outcomes.
- Failure to achieve primary outcomes would constitute a Type 1 error which would make any trial irrelevant.
- The treatment regimens in ASCOT compared an established regimen (amlodipine) with a
underpowered regimen of atenolol, which could potentially mean the trial was skewed from
the outset.
- If anyone is so inclined, you check the various feedback here if you enter BMJ via your uni's
Athens code.

Bottom line? even though I am not a fan of looking for problems when there are none, and creating controversy out of molehills, I think I've seen enough to understand why evidence-based medicine is both necessary and yet so dangerous when wrongly manipulated. Consider this maybe hypothetical situation:

NHS is in the unenviable position of having to govern the medical profession in the UK and having to promote and encourage drug research as well. In between keeping both happy, compromises have to be made, sometimes at the cost of the public. Say due to the results of trial A sponsored by drug company X, reception by the public is great. Suddenly everyone who has that illness wants to be on drug A. New guidelines are drawn up to accomodate drug A while people request that their treatment be changed to include drug A. What people do not realise is that these results, while looking good in the news, may not necessarily hold water under critical analysis. And while changing people to drug A may not cause any unwanted side effects (even if real evidence shows that actual benefit is negligible), people forget the cost involved.

Case in point: Cervical ca screening guidelines changed from 5 yearly to 3 yearly.

Surely more money involved rite? But is it cost effective? To get an idea, listen to the question as proposed by a article:

"Suppose you are faced with the decision about investing GBP 385,000 annually to benefit your local population. You can prevent one death every 22 years by routine 5 yearly screening beyond age 50, one death a year and harm an extra 1,000* by switching to 3 yearly screening under 50,

OR

10 deaths a year through support that helps smokers stop, and have enough spare to provide first rate nursing care and family support at home for 183 patients facing death from cancer.

Which would you choose?"

*by false positive diagnosis

Which means, hypothetically, NHS are going to lose even more money and the public are not going to get healthier, and docs are not going to get paid more, rather the reverse. Which has implications for those of us wanting to stay back.

Haha I sound like a bitter old cynic now.

Guess the whole point (wow if you're still reading you must really be into this. *pat on the back!*) of this is, the realisation never to take anything at face value, no matter how amazing the news sounds, and how credible the source may sound. And the need to really start keeping myself up to date on these things..cos patients know so much more than us its scary.