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Dr Butterworth (March 2004 JRSM1) describes how a relative of his was diagnosed as hypertensive and put on a succession of medicines with near disastrous consequences. This chain of events had nothing to do with the vogue for evidence-based medicine. Rather, it reflects the enormous difficulty of practising good and safe medicine in the era of effective but dangerous drugs. The proliferation of life-prolonging as opposed to symptom-reducing drugs makes clinical medicine complex and time consuming—though no-one would guess this from the mass of guidelines and protocols and the devolution of traditional medical tasks to non-doctors, all based on a fundamentally faulty world view where everything is either right or wrong, good or bad, black or white. Such reductionist inanity now extends to assessments of massive hospitals or even the whole NHS.
It was not what clinical trials have told us about treating hypertension that poisoned Dr Butterworth's relative. Whether he met any standard criteria for hypertension requiring drug treatment is not clear. To treat consequent dizziness with another drug appears simply crass; life, however, is complex, and we do not know the patient's blood pressure at the time this decision was made. Under-treated as well as over-treated hypertension can cause dizziness. The wise old general practitioner who took him off all medications may well have saved this man, but for all we know has over the years missed the opportunity to prevent dozens of strokes by adopting a ‘common sense’ approach to the management of hypertension in the asymptomatic elderly. Common sense, like evidence-based medicine, should be used only when appropriate.
Thank goodness we live in the era of dangerous and powerful drugs. Though the public may think that brain surgeons or heart surgeons have the most challenging jobs in medicine, in future the most difficult tasks will be polypharmacy in the elderly with multiple medical problems, to achieve the best combination of wellbeing and longevity. To master those arts will require lifelong education, natural empathy and most importantly, time and desire to think before prescribing. It is not the concept of evidence-based medicine we need fear, it is that of immediately demonstrable value for money.