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I read a story about WC Fields. Apparently a friend called to see him when he was dying and was surprised to see the hard-drinking, misanthropic comedian intently absorbed in the Bible. The friend asked him if he was seeing the error of his ways but Fields put him straight ‘I'm just looking for the loopholes’.
Perhaps I shouldn't admit it in a respected journal like this, so please don't mention it to the serious folk from the Front Pages, but I seem to be increasingly approaching academic papers and evidence-based medicine with the same philosophy. Maybe I'm just changing into a Luddite as the years go by but something about the relentless trend to medicalise and intervene grates with actual day-to-day experience as a GP. The world of acronymed, international multicentre trials is often completely at odds with the world I come across on an everyday basis. Their model of the world resembles some teeming ant hill where we all scurry around in predetermined, stereotyped simplistic ways. Their conclusions may apply for large populations but individuals are different, complex, often fascinating or frustrating and unpredictable. I am less and less convinced that large trials translate smoothly into appropriate care for individual patients.
The increasingly complex world of prevention and polypharmacy concerns me. I worry about the harm it sometimes causes, not just through conventional side effects, but a more subtle harm that can happen when doctors take control away from people and convert them into patients. More and more folk are being told that although they might feel well we know better; their blood pressure is a few mm of mercury away from normal or their cholesterol is a bit raised or a handful of clumsily worded questions has shown that although they didn't realise it, they are actually depressed and need treatment.
When evidence-based medicine recommends intervening less and giving back control to the patient I feel a rather childlike joy in finding a loophole. Managing back pain has transformed from advising patients to put their lives on stop — 2 weeks strict bed rest, plaster jackets, and immobility, to encouraging them to be back in control, keep active, be optimistic, and expect improvement.
My wife is a physiotherapist and has been telling me of a new promising treatment for Parkinson's disease where patients are taught to walk to a steady beat from a metronome. This apparently simple technique seems to improve their mobility after about 3 weeks training and they get back control of their illness without the need to passively rely on increased doses of medication which often have unpleasant side effects.
Another little gem I came across recently was a study in European Heart Journal, which concluded that ‘staying active and drinking moderately is the key to a long life’.1 A pleasant change from most studies that advocate more monitoring, measuring, and medication. It's stark simplicity, compared to the trend towards more and complex intervention, reminded me of a quote from another colourful entertainer. Noel Coward was in a discussion about the art of acting. There was lot of intense talk about the struggle of finding motivation and getting into a character, when he piped up with his secret ‘Learn your lines. Speak up and don't bump in to the furniture’. Simplicity can be deceptively powerful and satisfying.
Paradoxically handing control back and intervening less can mean taking more responsibility for a patient than when slavishly following generic protocols. The art and wisdom of medicine is knowing when to back off and keep things simple. Knowing when to walk to a different beat.