Thursday, 17 December 2009

Worried well

This week has brought James (23), Mark (35) and David (55). None of these men have any symptoms, and yet all were coming with deep concerns, all of them requesting a general health check, a 'medical MOT'. They've got their reasons. James has recently become a city banker. He now spends approximately 14 hours a day in an office, can no longer find the time to exercise, eats junk food at his desk and has put on 2 stone of weight. Ah, these poor bankers. Mark on the other hand is the healthy type. He cycles to work (lycra clad), eats organic, takes part in triathlons and shops with a re-usable hessian bag. But an equally healthy living friend has just been diagnosed with cancer and now he too feels vulnerable. David is a man in his 50's who has heard about prostate cancer.

Such non-specific but deep rooted health concerns are becoming more and more common. They're encouraged by health horror stories from family, friends and from the media and deepened by searching on the internet. Privately, you can have screening blood tests, full body scans, computerised images of your brain, blood vessels or intestines - pretty much anything and everything that takes your fancy. But I wonder whether this is something that should be encouraged? The NHS doesn't think so, as apart from anything else it is about as cost-effective as a diamond encrusted toothbrush. But if money was unlimited, would it be a good idea for us to be fed through a scanner at regular intervals, just incase?

As far as I'm concerned, the answer should be a definite no, and I'll use David as an example of why. His request for a blood test to screen for prostate cancer was a perfectly sensible one. Prostate cancer is the second most common cause of cancer deaths in men in the UK, and it becomes more common over the age of 50. So, after a long discussion about the pro's and con's of testing, he went ahead and had the test. But it's no easy decision, as becomes apparent when you take a closer look at these pros and cons.

Pro's: If the test is negative, you'll feel reassured. If it's positive, you may pick up a cancer early, get treated quickly and not die. That's a pretty big pro. But here are the con's: 2 out of 3 men with a positive test will not have prostate cancer. This means that two thirds of men who go on to have a biopsy will turn out not to have cancer after all. When you know that a biopsy means having a probe with a needle attached inserted through your rectum and into your prostate this suddenly seems like a notable con. It doesn't get any better from here either, because if you are unluckily enough to have a positive biopsy result, there's often no way of telling whether the cancer that you have would ever cause you problems. Some do, some don't. So then you must decide whether you want to have treatment which can involve surgery (with the potential of nasty complications including impotence), radiotherapy and chemotherapy. If you decide not to, you have to live with the knowledge that you have a cancer that may or may not kill you. There's one further important con, and that's that a PSA test can miss a cancer and so can a biopsy.

The NHS has decided that the cons outweigh the pros in this case, and so whilst you can have the test if you ask for it, there is no national screening program in place. But this is just one disease. Imagine the possibilities for misadventure if we were to look for any conceivable problem with our health, year in and year out?

So whilst David had his test (it was negative), I tried to persuade James and Mark that in most cases, ignorance is bliss. I'm not sure that I did a great job of convincing them and I wouldn't be at all surprised if the private sector gets some revenue from these two. For me though, I'm just not in the business of looking for trouble...

Thursday, 10 December 2009

Yours or mine?

Sometimes it can be pretty hard to know where my responsibilities start and finish when it comes to patients. Take Martin, who was worried that he might have thyroid disease. Having read on the internet about the symptoms of tiredness, weight gain and low mood (average British person in mid-winter?) he made an appointment to get some bloods taken. We discussed that he should telephone in 3 days time for the results, but as often happens, he never did. Should I call him?

David obviously thinks so. He came in for a repeat prescription this week and in passing mentioned that he had never found out the results of a blood test taken over a year ago; 'I assumed if there was something wrong the doc would have called me'.

Actually, there's no real question that checking test results is a doctor's obligation. After all, if we're not interested in the results, why bother doing the test in the first place? But at the same time, I do find it a little frustrating if a patient doesn't also check for themselves. It's largely because it increases my work load but it's also because it gives the impression that by coming to see me they have absolved themselves completely of all responsibility for their own health.

Another example is that of Mr Shaw. His problem was of food sticking in his throat when he tried to swallow. This was worrying, and so I referred him to a specialist straight away. I explained that he needed to telephone to make the appointment himself but on checking my outstanding referrals a few months later I saw that he had never done this. Despite the fact that we had discussed a plan which he had understood and agreed to, he had not followed the instructions. So should I chase him up? Is that my responsibility? (In this case I did, and I'm sure you'll be pleased to know that his symptoms have resolved)

Of course there's no black and white answer here and in practice what you do and don't do for your patients comes down to how worried you are about their symptoms and what you can realistically achieve. It just isn't possible for any one doctor to keep tabs on all of their patients all of the time. There are too many uncertainties: Are they attending appointments? Are they picking up prescriptions? Will they come back as I asked them to? With thousands of patients on your list, these questions will inevitably often go unanswered.

To some extent then, you have to be able to rely on patients to be accountable for themselves, to take back some of the responsibility. This isn't a risk free strategy. There are always going to be situations when there is a mismatch of expectations between patient and doctor and in these circumstances there is a real danger that something important could get missed. Fortunately for me it seems that on the whole my patients are worryingly well versed on the fallibility of doctors (...must have been the one before me...) and so, with a bit of teamwork, we seem to be doing pretty well.

Thursday, 3 December 2009

Big Brother

We've had a new healthcare initiative added to our remit this year. The idea is to screen as many of our patients as possible for alcohol misuse, with the aim of making people more aware as to what constitutes dangerous drinking, and helping them to make changes before it is too late.

According to the Department of Health, 23% of adults aged between 16 and 64 years are thought to drink at hazardous or harmful levels. This includes a massive 32% of men (15% of women), and equates to approximately 7.1 million people in England.

Some definitions are needed here. The World Health Organization divides alcohol problems into three main categories; hazardous drinking, harmful drinking and alcohol dependence. Hazardous drinking describes drinking above safe levels, 14 units a week for women and 21 for men. Harmful drinking is the same but with evidence of alcohol related problems. Alcohol dependence has a much more complicated definition but basically describes the group that we would know as alcoholics.

So what's interesting about the 23% statistic is that it isn't talking about alcoholics, but about people who drink in excess of what the medical profession considers safe. It's referring to anyone you know who drinks more than a couple of glasses of wine a night, and according to the stats that's nearly one in four of us - in reality, it's probably more.

The problem of course, is that this group of drinkers doesn't think there is a problem. The government and the NHS do however, and in fairness, rightly so. Any sort of prolonged hazardous drinking can lead to liver disease, heart disease, even some cancers, and that's before you look at the social problems of relationship breakdown, financial problems and alcohol related crime.

So I do understand this drive to identify problem drinkers, and there's evidence to show that some brief advice from your GP can make all the difference. On the other hand, actually performing this mass screening is pretty uncomfortable. It's understandably difficult to launch into questioning someone about their alcohol intake when they've come to ask you about a toenail infection. It hasn't happened yet, but I'm just waiting to be told to mind my own business, an attitude that I would sympathize with completely.

So the point is, is it our business? The powers that be would say that anything that impacts on the nation's health should be, but as individuals surely we must be allowed to make at least some of our own lifestyle choices. I feel pretty strongly that what we eat and drink should be one of them. However that then leaves the question of where to draw the line; is smoking a lifestyle choice? Is injecting heroin?

It all comes back to that age old conflict between wanting to help and interfering, trying to protect and smothering. I have no desire to play the role of nanny, and yet I have seen the desolation that problem drinking can bring. So I do my best to follow this new initiative where I can, apart from anything else we will lose out financially if I don't. I try hard not to be too intrusive. As for how much the toenail guy drinks though, I didn't ask.