The Doctor’s Surgery
It is a melancholy task to take up the baton of someone who has died, especially when you knew and respected him. Dr Tom Stuttaford had precisely that scepticism without cynicism, as well as actual experience, that made him such an excellent medical columnist and adviser.
And a certain degree of scepticism has never been more needed than today, when medical information bombards us from every direction and raises both our hopes and our fears.
Someone in the BBC once told me that the BBC is under instruction to include a certain amount of medical content in its new bulletins. Since I never listen to the BBC, I have been unable to verify this. But I have checked newspapers, comparing those of the 1950s with those of the 1990s, and the medical content increased pari passu with the decline in foreign news, and even more than our increase in life expectancy.
It is only since my retirement from practice that I have had the time to read the scientific papers in medical journals with anything like thoroughness, and I have been surprised by how bad or inadequate many of them are.
You can tell, for example, when researchers have found something trivial when they give you the relative risk of contracting a disease associated with some factor or other (often enjoyable) without giving you the absolute risk.
My advice to someone who is told that taking a certain pill every day will reduce their risk of a future disease by, say, 25 per cent, is to ask for the absolute figures. A very large reduction in a relative risk may translate into a very small reduction in an absolute risk, and moreover may come at a considerable cost. This might explain in part why 50 per cent or more of those prescribed pills for high blood pressure stop taking them before the year is out.
The so-called gold standard of medical evidence is the controlled trial (I leave it to economists and economic historians to decide whether gold standards are a good thing in the Sellar and Yeatman sense). But when you go to the doctor, you go as an individual, not as a member of a group. Controlled trials can tell you whether a treatment is better or not than a placebo (or other treatment) for a group of similar patients, but it can’t tell you whether it is better or worse for you. If a trial is large, there may be sub-groups to which its results do not apply.
On the basis of controlled trials, the National Health Service will soon cease funding 17 procedures, for lack of evidence of efficacy; 350,000 of them are performed each year, among them steroid injections for non-specific low back pain. This, of course, is a boon for private practice; for patients in distress are willing to give anything a go, and doctors can easily persuade themselves that they are doing things for the benefit of their patients rather than for money.
Once, in Africa, I had a patient with cerebral malaria who had not recovered as expected and remained restless but unconscious. As it happened, I had just read a report of a controlled trial establishing, at least until another trial proved the opposite, that intravenous steroids were useless in this condition. Because of the desperate condition of my patient and thinking that there was nothing to lose, I gave him intravenous steroids. His recovery was dramatic and so immediate that it was difficult to believe it was a coincidence.
What does this prove? Not very much, except that Hippocrates was right: life is short, the art is long, the occasion fleeting and judgement difficult. Especially the last.