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Last year one of our grandsons, then aged two, had a plastic Tyrannosaurus rex called Olive. I don't understand why little children find dinosaurs so appealing, any more than I understand why he chose that name, but I approve of the basic idea because I am a bit of a dinosaur myself.
Anyway, just at the moment we extinct species are indulging in Schadenfreude, it seems that our instinct was right all along, that current protocols label far too many people as being at high risk of ischaemic heart disease and that far too many have been frightened or coerced into long-term medication.
The Guardian newspaper picked this up as its front page lead on 8 July with the headline: ‘1.5m wrongly told they risk heart disease. Misdiagnosis has led to massive over-prescribing of drugs — BMJ study.’ Strangely, the paper was not among the three items of original research which were included in the ‘compact edition’ of the BMJ which was in the post the same morning. Nor could I find it in the full edition on the BMJ website. Further cunning delving, however, eventually tracked it down to a pre-publication paper in the ‘Online First’ section of the eBMJ.1 This makes it quite likely that its appearance in hard copy will coincide neatly with this issue of the BJGP.
Whatever the outcome of the discussion that will surely follow, and whether or not the new British-based QRISK algorithm proves as superior to the old Framingham-based one as the authors of this study claim, there are more general lessons to be learned about the wisdom or otherwise of imposing such schemes on whole populations by diktat from the centre.
My own favourite reason for opposing what Petr Skrabanek called ‘coercive healthism’2 (of which this is a superlative example), is this problem of centralised mistake making. Mistake making is part of clinical practice, we all make mistakes, and individual doctors are hardly less prone to this than remote committees composed of experts. But the great danger with centrally-imposed mistake making is that everybody makes the same mistake at once, which can be as dangerous to humanity as a novel fungus is to a monoclonal cereal industry. When dealing with matters of life and death, as tends to happen in medicine, and with issues of gigantic public expenditure, the error is undiluted by the protective diversity of nature.
Secondly, the traditional kind of medical practice, so quixotically defended by us dinosaurs, was based on human judgement and understanding. Almost everything was flexible and relative and there were very few absolutes. The trouble, once again, with externally imposed treatment protocols, especially when those protocols are linked directly to payment, is that they are treated as absolutes, and liable to be applied without discretion. If we treat doctors as passive operatives in a mechanical system, the consequences will eventually come back to bite us.
Patients need real doctors, and that means society needs them too. Real doctors must have much more clinical freedom and discretion than ever appears necessary to external observers, whether they be politicians, journalists, or experts in circumscribed fields. The boundaries to such freedom must be clearly defined and inviolate, of course, but the bias must always be to set them as widely as possible, and that means much more widely than we would ever think ideal. But there I go again, I have been saying that sort of thing since the age of the dinosaurs.