Columnist Dr Copperfield welcomes a small dose of reality in the deranged world of clinical guidelines
I realise we’ve barely reached spring, and that the Jurassic, cynical and clapped out aren’t supposed to trouble themselves with ‘the medical literature’, but the truth is, I’ve already decided on my paper of the year. It’s called ‘Guidelines should consider clinicians’ time needed to treat’, it’s in the British Medical Journal and it’s excellent.
It points out that applying all US guidelines for prevention, chronic disease and acute care to a list of 2,500 patients would take up to 27 hours per day, and that implementing all NICE lifestyle recommendations in the UK would require more doctors and nurses than are currently available, presumably even if they worked 27-hour days. This is why you feel a) There’s never
enough time (there isn’t) and b) Utterly knackered (you are).
How refreshing to read someone acknowledging that professional time and energy is finite and adding a dose of reality to the deranged, relentless world of guideline generation. These researchers (Johansson et al, if you want to check them out) deserve a statue in their honour.
And that shouldn’t be difficult: there’s plenty of plinth space, given that statues are being hauled down all over the UK as we pay penance to our imperialist past. Which is neatly appropriate, because what Johansson’s paper highlights is, in fact, medical colonialism.
Wherever you care to look, we are expanding our medical empire by colonising people’s minds and diaries with more medicines, interventions and appointments. Fears around illness have evolved from obsession to existential threat, and perfect health must be preserved at all cost. And the medical profession is largely to blame.
Consider the following. Screening is increasingly leaving no orifice unprobed, with poorly evidenced programmes entering by the back door (as Pulse’s April/May cover makes clear). Thresholds for diagnosis and intervention are continually lowered (hypertension, QRISK, diabetes, pre-diabetes, pre-pre-diabetes, etc). Incidentalomas and their follow-up protocols are as inevitable post scan as patients wasting appointments wanting us to chase up the results. New and soft diagnoses expand to fill ‘unexplained symptoms/variation of normal’ vacuums (B12 deficiency, subclinical hypothyroidism, ADHD, Long Covid et al). Overdiagnosis results from overtesting and overinterpretation (CKD, prostate cancer, borderline melanoma, thyroid cancer). New medications that are a drop in the medical progress ocean but a massive drain on resources are trumpeted as breakthroughs (take your pick). ‘Checks’ have reached sanctified status (self-checks, chronic disease checks, health checks, annual LD/SMI checks, BP checks, frailty checks, checks to check you’ve had your checks, etc).
Everyone, everywhere, from the media through charities to your local hairdresser is part of this crusade to prioritise health by constantly cajoling us to be screened, scanned, diagnosed, checked, monitored and drugged to within an inch of our lives.
And this is before the patient starts mentioning symptoms.
Which begs the question, whose life is it anyway? Can the individual choose how relevant the pursuit of health is, or must the medical profession exert imperialistic dominance and control? And what is the purpose of life, anyway? To doggedly exist as long as the medics can keep us going? Or to enjoy the opportunity of a lifetime?
Dr Copperfield is a GP in Essex. Read more of his blogs here
Well said Tony!
It’s probably too late!
(cancelling FATPOA might be a start though)
Brilliant
Totally agree with this and try to make the patient reach this conclusion with me when I’m not running behind… Medicalised target reaching perfection when we’re all going to die anyway surely can’t be what life’s about
Just laugh at it all, and you’ll be fine——–look at me
👏👏👏
I have been reading your column since you started them many years ago- I even have your book- and usually they are brilliant. Very disappointed to see you state that ADHD and Long Covid are ‘soft’ diagnoses. For the first time ever I am glad that none of my family and friends are your patients and that makes me sad. I expected better.
Totally agree with L Hertel’s comment, while I agree with the general flavor of the column. ADHD is real. I’ve seen “ social anxiety “ being dismissed in a similar fashion. You do have to be careful with examples.
You two, get a grip. He’s not saying soft but new and soft and in the context of overdiagnosis he is entirely correct. Heard of second gains? Projected fear? Locus of control? Family dynamics? Comorbidities? Google it if you want. Plenty of evidence. I have ADHD which makes me not only rude but sometimes quite irritable and impatient, especially with those who choose to ignore the amount of effort and money that goes into the honorable task of building up evidence. And sorry but I can’t be bottomed to provide the link; it’s out there for everyone to – yes! – GOOGLE. Overdiagnosed AND underdiagnosed. Now developing your instinct of which one it is in a given encounter is what we’re good at.
In this fortunate age of more and more complex treatment options for debilitating and life-changing diseases with focus on extended, good quality life spans pursued by poorly paid researchers and our noble specialist colleagues, yet centrally driven cultivation of a mindboggling attitude towards reason, tolerance of impulse and regression with the behaviour to match, less uptake of screening and vaccines, hostility towards science and its advocates and this at astonishingly full mental capacity, more conspiracy and other utter-nonsense beliefs than ever, not to mention the stasiistish corruption of the apparatus feeding all of this, the whole gulf widening with my dopamin-hungry cortical waist, ADHD and Long Covid should quite rightly come further down the list. At least when it comes to waits for appointments and frequency of follow-up with US. As in us, the GPs. It doesn’t do anyone any good if we give in to every demand the battle-hardened, not-really-weak-when-it-comes-to-that, overdiagnosed cohorts have on us. There are numerous self-help sites, videos and forums out there for us. As in us, the ADHD “sufferers” (as it’s both, loss and gain). I know. Now. I was flabbergasted to dive into the amounts of information one can utilise for free. Good for really great advice, having a new group of peers to make friends with, even wallowing in things for a good while is fine with masses of like-minded folk helpfully at hand to commiserate – and sneak in their own story obviously but that alright by most – until the penny drops and suffering comes to its natural end. That is that one is alive not forever and life is better lived than spent on regret and revolving around one’s mousy timid self. Or to MAKE an appointment but one with the clear request for treatment.
Again, the evidence that it helps to leave us – the people – to our own devices once we show a bit too much care attachment is out there. We can with justification more often say no to them and instead yes to those whose lives really need us. Become distributionists fair and square. Sorry for waffling. It’s the ADHD.
@ Bettina Schoenberger
That’s an interesting ‘waffle’ and I basically agree with you.
TC was just making an informed and amusing commentary.
Thanks Tony for the light hearted article and I am sure there are real ADHD and Long Covid around and they are easily spotted and they are few and far between but these have now been milked to no end for advantages and benefit gains. I would say these fakes drown out the real patients and they do not want to get better for these gains.
People really are developing sense of humour failure, when they take offence at a satirical take on our crap (living the dream?) jobs. Coming soon to an overdiagnosis near you – Sense of Humour Failure (SOHF).
Keep them coming Tony! You always make me laugh at your incisive and indeed knowledgeable take on all aspects of our toil!
Anyone with an ounce of insight will know that you are an excellent, caring GP but also one that you would be happy to go out for a pint with!
@Lise and @Richard
“Soft diagnosis” doesn’t seem to be a very widely used phrase but Google informs me it means a suspected but as yet unconfirmed “case” of a particular diagnosis. The example given by Urban Dictionary is “my cat has a soft diagnosis of cancer”.
So I’m not entirely sure Tony is saying that these conditions are non-conditions. But then who knows, other than Tony?
great article!
shame was not brave enough to question status of obesity as “illness” (or maybe saving it for later?).
oops…have I just mortally offended 60% of our adult population?
Some Bloke———–including our former Health Secretary
John- if that individual had emotional capacity or humility to feel offended, I’d be congratulating myself on mission accomplished. (Wouldn’t call it a precision strike, but got one of the targets anyway.) But I suspect she will survive and continue her “important work for the country”, unfortunatelly…
I thought Long Covid was the New Fibro. Just as amorphous, just as untestable, just as little evidenced, and treated just the same, i.e. the drugs don’t work, and don’t stop doing things. Clinics are just hand-holding. As for all this screening and stuff, Tony’s given me an idea. How about we only see patients who actually have a symptom? EVERYTHING else is protocol driven and doesn’t even need a clinician.
@Dr No
At my practice much of the procotocol-driven stuff is automated by the office (EG automated text to pt requesting that they check their BP in the machine in waiting room…), sometimes involving the nurses, rarely the GPs.
But while has one benefit of keeping the doctors out of the protocol stuff, it also turns out that protocols are more likely than doctors to lead to further intervention. For instance, I would often say to a patient “the textbook says you need a statin etc etc etc but I think you’re doing just fine as you are. Shall we leave things as they are?”. The protocols never say that.