Editorial Note: The RxISK Report function on RxISK has been streamlined. We want you and everyone who can to fill reports, take them to your doctor pharmacist or nurse prescriber and report back to us. There are two reasons to do so.
First, you are getting $150.00 worth of RxISK Report for free – it seems a shame to leave it sitting on your computer doing nothing.
Second, when you take a RxISK Report to a doctor you are engaging in one of the most revolutionary acts of modern times – you will either find someone on your side or will come face to face with the System. You will have your own personal Matrix Moment. You mission should you decide to accept it is to help all of us map where our people are.
Cars & climate
When I was young, my parents contemplated getting a car. At the time my father could take a bus to work. We would walk to church which was a mile away. The shops we needed were only a quarter of a mile away. I could ride to school on a bike. Cars were not necessary. They were a luxury.
Ten years later cars became a necessity. Dublin had grown vastly as most cities had. The suburbs were further out. The population had outstripped public transport. While the same shops were still a quarter of a mile away, bigger and better shops were further away but needed a car. The way we lived marketed cars without the automobile industry having to do much.
As this happened, the combination of cars and Oil began to contribute hugely to Climate Change. Faced with climate change now few of us can see how our actions could make a difference. Taking to a bike just doesn’t feel like its doing anything.
Before the 1980s in Ireland partly because women were more likely to be at home very little of the food that people ate was processed or convenience food. It was cooked and baked on the day. Convenience or processed foods were something exotic to entertain the palate from time to time.
As women began to go out to work and shopping was done in hypermarkets at weekends and had to keep through the week, processed foods became the norm.
But in the last ten years we have seen a revolution against fast foods. Unlike transport, this revolution has been successful. While the majority of the population still takes processed foods and a huge food industry lobby has a grip on policy and politics, there is a significant resistance movement which is unlikely to go away.
In both these cases we can see what marketers describe as a distribution channel. The goal of marketing is to get to the kind of situation where the environment sells the product.
They used to call it medicine
In the 1960s and 1970s the hallmark of a good doctor was that they knew when not to treat you. Doctors treated the person in front of them, looking and listening to them and responding only to the problem that the patient had brought. Medicine was a relationship – albeit a paternalistic one then.
In this relationship drugs were a poison to be used judiciously with the art of medicine lying in knowing when to use the poison and in what dose. Drugs were an option – they were part of the therapeutic armoury.
But just as cars became the answer to transport, and convenience foods the answer to eating, the human body – not just health care – has become something to which a drug is the answer. This is true for issues from the need to have unblemished skin, to old style medical emergencies like heart attacks or new style risk management with drugs to avoid bone-thinning or nervous problems.
The relationship between doctor and patient has broken down. We rarely see the same doctor on successive occasions. Doctors increasingly resemble technicians treating numbers and risk factors rather than the complaints that a patient brings to them and the numbers are treated according to algorithms and protocols. Continuity of data has replaced continuity of care.
The numbers are something that a drug is invariably the answer to. Drugs are not optional here. A failure to treat the numbers is likely to be regarded as malpractice. We are now less likely to get treatment for a problem we bring to a doctor and more likely to have a doctor who is responding to some requirement from above to screen for a range of risk factors and treat.
Where once doctors were sceptical of new drugs and curbed patient enthusiasms, now they are part of an environment that promotes drugs – a key part of a distribution channel. Adding more pills has become the usual answer to any problems that pills cause.
Big oil – big RCTs
Just as cars and oil have combined to produce climate change, so drugs and Randomized Controlled Trials (RCTs) have combined to fuel a change in the climate of health.
In the 1960s, there was a range of ways to evaluate whether a medicine was working. The doctor might look at the patient for clearly visible benefits or harms, supported by test, retest procedures. There were some laboratory tests to determine whether particular disturbances had been reversed.
When RCTs emerged in the 1950s, it was recognised that they were of limited utility – likely to turn up the wrong answer in many instances but useful in some cases.
A drug disaster with thalidomide in 1962 catapulted RCTs into new FDA regulations for evaluating drugs. All of a sudden trials moved from being optional to being mandatory.
But since then the drugs brought to the market have been weaker and more likely to be recalled for adverse events than those brought to the market before thalidomide. Despite this, RCTs are trumpeted as the gold standard method to evaluate drugs, with the observations of what actually happens to a patient in front of a doctor’s eyes degraded to the status of anecdotes.
So in the case of cars, although our climate may be changing disastrously, the cars we use get better and safer. But in the case of medicines we get disastrous climate change and weaker, more dangerous drugs.
The right stuff
When a patient visits a doctor now, if they have treatment preferences that do not coincide with their doctors or if they have an adverse event, they are increasingly likely to have their experience invalidated. This is a profoundly demoralizing and dehumanizing moment. (See Fragile Doctors, Suicide is Painless, Getting Engaged to a Doctor).
Few doctors appreciate just how difficult this moment can be for even well-educated and assertive patients. To be a patient these days increasingly requires us to have The Right Stuff as we try to call on any reserves of The Right Stuff our doctor still has.
Because it involves a meeting of two people, this is one of the few points, where an individual in the modern world can confront the world in which we all live and can make a difference to that world. When we opt to walk rather than drive, it doesn’t impinge on a car salesman. When we prepare our own food rather than eat processed food, it probably strengthens those we eat with but doesn’t change the System.
But if we engage our doctor and refuse to back down, we force him to face up to the worldview he has internalized that at least in part dictates how he practices. If we engage a doctor who is already trying to practice what used to be called Medicine, we reinforce her and help establish another node in a network. Helping that network to spread is one of the single most radical things anyone on this earth can do.
We need to set free the least free market on earth. We need to ensure this market meets our needs if both it and we are going to survive. The alternative is a healthcare totalitarianism whose outlines are becoming ever more visible.
Many doctors are aware that medicine is sick. Many of us are aware that we are not fully aware of how marketing works on us. We do not have the tools to deconstruct clinical trials. We have heard that a huge proportion of the literature that shapes what we prescribe is ghostwritten and that the data from clinical trials are inaccessible, but how do we tackle that when our governments and professional bodies turn a blind eye to it.
Our problems are sometimes pitched in terms of Might versus Right, or speaking Truth to Power. But the idea that any of us should be expected to willingly step into the firing line is romantic and unrealistic.
Framing the issues in terms of Might v Right is neither correct nor helpful. It is not a matter of speaking truth to power. It is a matter of dismantling a distribution channel. Those who created the Slow Food movement didn’t speak Truth to Power, they followed their preferences. The big difference here though is many people pushing for Slow Medicine will be faced not with a delicious aroma of spices and herbs but with some of the nastiest and most undermining moments possible.
This applies both to patients facing Fragile Doctors but also doctors who try to do the right thing.
Back to you
Take a RxISK Report to your doctor, pharmacist or nurse prescriber tomorrow or help someone else to do so. It may save your life but it may also help make the world a better place. Report back to us what happens – tell us if your pharmacist or doctor is one of us – help us set up a Good Prescribing Quality Mark system.