The Macbeth Test

Editorial Note: No one outside the UK may be paying any heed to the all-consuming debate within Britain about the referendum on the future of Scotland. Everything comes back to this. Corporations have been saying they’ll pull out if Scotland leaves the UK (Standard Life) or that they’d prefer if Scotland left (British Airways). The EU have said Scotland would have to wait 5 years to apply to join the EU – until they had proved they could make a go of it alone – but haven’t said the same thing about a newly independent England.

So it’s time for RxISK.org to make clear its position on Scottish independence. Take the test and then see below.

The Macbeth test

Be these juggling fiends no more believed

That palter with us in a double sense

Keeping the word of promise to our ears

But breaking it to our hope

A medical Macbeth has overthrown the gentler and wiser Duncan. As things go badly wrong he will always opt for more of what caused the problem rather than trying to step back.

At the behest of the Witches, he uses guidelines and screening tests. But the guidelines are for diseases rather than people and the screening tests create rather than solve problems.

This test to detect the influence of the Witches works on the premise that we should treat people not diseases:

1. You should not be on more than 5 medicines other than in exceptional circumstances.

Score -2 if you’re on nothing, 0 for 1-4 meds, +2 for 5-8 meds, +5 for 8 or more meds.

2. Your doctor should acknowledge that neither he nor anyone has access to the full dataset on any drug he prescribes.

Score -2 for acknowledgment of this.

Score +2 if he insists he prescribes according to good evidence.

3. Your doctor should treat you and not your measurements. Excellent treatment would have minimal or no measuring in the course of treatment.

Score + 2 for each test from Box A.

Score -1 for any tests from Box B.

4. The complaint/problem you bring to your doctor should be the focus of treatment, not some problem your doctor tells you you have.

Score -1 for each problem you brought to the doctor.

Score +2 for each problem your doctor said you have.

5. You should only take treatments that are proven to save lives – most treatments aren’t.

If your doctor can prove your treatment saves lives score -1.

If he says he is treating a risk factor score +2.

6. Treatment should improve your ability to function not laboratory measurements.

Score -1 if you are able to do more on treatment.

Score + 2 if you are able to do less.

7. For each treatment you are on from Box C or D below Score -1.

For each treatment from Box E, Score +2.

9. You have a right to ensure your doctor is not treating you to meet s target set by his employers, a guideline committee, or the government.

Score +5 if your doctor has called you in for a screening program or you suspect you are doing more for him than he is for you.

10. Many people need less than the ‘usual dose’ to get a good effect. A prescriber who starts on a lower than ‘usual’ dose and watches what happens is a good prescriber.

Score -2 if your doctor starts you on half the lowest dose or uses older medications in low doses.

Score +2 if your doctor goes beyond the recommended highest dose.

11. In older age you need to be treated like a vintage wine – with care. You are more susceptible to side effects and interactions. Get your doctor to take the birthday test: Each birthday ask him ‘which drugs can I stop?”.

Score -2 if he stops one or more.

Score 0 if you are on only 1 or 2 tablets to begin with.

Score +2 if he refuses to accept there are any drugs you could stop.

12. Don’t take drugs for diseases you don’t have.

Score -2 if your doctor has not attempted to give you a disorder from Box F.

Score +2 if you have been given a diagnosis from Box F.

13. Your doctor should be worried that you have all the information you need to choose and not worried by your choice.

Score -2 if your doctor supports you in decisions to avoid treatment.

Score +2 if your doctor finds it difficult to accept your choice.

Score +5 if he attempts to do a Mental Capacity Test on you.

14. The bigger the number of people entered into trials of your treatment the less helpful this treatment is likely to be.

Score -2 if the main trials on your treatment had less than 100 people in them.

Score + 2 if the trials had over 100 and less than 1000 people in them.

Score + 5 if the trials had over 1000 people in them.

We would until recently have said “if your doctor scores more than 10 on this test, consider leaving Scotland – unless of course you attend his or her clinic for the scenery rather than the advice”. But Westminster seems to be where the Witches are based at the moment, so perhaps consider getting a doctor from North of the Border if the Scottish Government comes up a good plan to escape the new Tyranny that is leading to the destruction of Medicine as it once was.

Box A: Problematic measurements

1. If healthy – any measurement including any rating of behavior
2. Mood rating scales in children
3. Screening for Prostate Specific Antigens (PSA test)
4. Screening for Bone Densities
5. Routine Cholesterol Levels in the absence of Cardiovascular Risk Factors
6. Screening for HbA1C/glucose levels if not diabetic
7. Regular Peak Flow levels
8. Depression Screening in Pregnancy
9. Mammography under 50 without a family history
10. Troponin T measurements

Box B: Helpful measurements

1. Cholesterol levels after a heart attack
2. Colon cancer screening if a positive family history
3. Cervical Smears
4. Neonatal screening for PKU, or thyroid problems
5. HIV screening

Box C: Life saving treatments

1. Coal Tar for Strychnine and other Poisoning,
2. Parachute for Sky Diving
3. Insulin for Type 1 Diabetes
4. Inhalational anesthetics for surgery
5. Gentimycin for Bacterial Endocarditis
6. Antibiotics (Penicillin) for Bacterial Meningitis
7. Thiazide antihypertensives for Severe Hypertension
8. Glivec for Lymphoma/Teratoma
9. Statins for Familial Hypercholesterolemia
10. ARVs for AIDs

Box D: Function restoring treatments

1. Thyroxine for clinical hypothyroidism (not for borderline laboratory abnormalities)
2. Benzodiazepines for catatonia
3. Tricyclic Antidepressants for Melancholia;
4. Antihistamines for allergies
5. Stimulants in cases of gross hyperactivity
6. Phosphodiesterase inhibitors in impotence
7. Anti-malarial prophylaxis (Not Lariam)
8. Folate pre-pregnancy and in first trimester
9. Morphine for pain relief

Box E: Treatments where the harms are likely to outweigh the benefits

1. Aspirin for prevention of heart attacks
2. Extended course of HRT
3. Statins for cholesterol elevation in the absence of other Cardiovascular Risk Factors
4. Biphosphonates for Osteoporosis
5. Long Acting Beta Agonists given alone for Asthma
6. SSRI Antidepressants if continued without a clear beneficial response,
7. Varenicline, Buproprion for Smoking Cessation
8. Antipsychotics for Treatment resistant Schizophrenia
9. Drug treatment for Lung Cancer
10. Drug treatment during first term of pregnancy
11. Antipsychotics in the elderly
12. Weight loss drugs

Box F: Diagnoses that put your life at risk

1. Pre-hypertension
2. Pre-diabetes
3. Osteopenia
4. Female Hypoactive Sexual Desire Disorder
5. Complicated Mood Disorder
6. Sub-Syndromal Depression
7. Juvenile Bipolar Disorder
8. Psychosis Proneness
9. Sub-optimal Peak Flow Disorder
10. Raised Cholesterol Levels in the absence of other cardiovascular risk factors
11. Adult ADHD
12. Adult onset Autistic Spectrum Disorder