Neville, a well-meaning GP registrar, had offered to treat the smartly suited Mr James for his alarmingly high blood cholesterol. The retaliative pronouncement seemed to be a secondhand truth, questionable both in its veracity and its relevance:‘No one takes statins in Scandinavia.’
‘My herbalist says that no one in Scandinavia takes statins, because they have dreadful side effects, and that I should take these instead. He's extremely well-qualified you know.’
Neville inhaled deeply, and tried to control the indignation burning up into his face as Mr James placed two tubs on the desk, one marked ‘Sterol-117’ — he proudly explained that this was a special hypoallergenic formula — and another marked ‘Choleast™.’ He produced a printed chart that showed several other complimentary therapies and finally unfolded an email from the therapist. The email suggested that he could take both the therapies and the statin, but ‘would not recommend this.’ Taking both could have adverse consequences, so he should avoid the statin. Mr James said:
‘I felt terrible tiredness a few years ago and he said that it was toxins under my teeth. He arranged for me to go to Switzerland and have four teeth extracted. I've never felt better. You wouldn't get that on the NHS; You can never see a doctor, and all the drugs have terrible side effects.’
Neville felt righteously angry — a ‘vulnerable’ man was being exploited by someone operating by an entirely alien set of rules to western medicine. He called up Mr James' blood test results on the computer screen, and showed him how, since he had stopped the statin, his ‘bad fats’ had doubled. How would he know which therapy was working if he took them both? Explaining that he could not recommend food supplements of unproven efficacy, he added that the vast evidence for statin usage was based on thousands of cases across a dozen countries. The landmark research was in fact from Scandinavia.
Unkindly, Neville told him that none of the therapist's qualifications were recognised by western medicine. This shook Mr James a little, ‘What about this one?’. He sheepishly indicated ‘Fellow of the Australian Institute of Idiopathic Medicine’ on the printout. Neville continued:
‘I am duty-bound to tell you that if you have a heart attack or a stroke as a result of not taking a statin on this person's advice, then you could sue him for damages.’‘I would never do that,’ Mr James looked horrified at the thought, ‘We have a fantastic therapeutic relationship.’
Neville perceived that he had overstepped the mark. The righteous anger faded. They agreed that they would both look up the supplements. Mr James agreed to take the statin, and Neville felt a pang of guilt for being a bully. A repeat blood test was planned for 4 months' time.
Neville looked up the products before discussing the case with his GP-trainer. Red yeast rice: there was a synopsis on Wikipedia: it contained an HMG coenzyme-A reductase inhibitor, a ‘natural’ statin, no doubt with a similar side-effect profile. A ‘healthy living’ website described sterols as naturally occurring oils to be found in any healthy diet that included fresh fruit and vegetables. Therefore the average US citizen was in dire need of supplementation. As he reflected that there might just be an evidence base for the therapist's prescription, he felt a little guiltier.
During that week's ‘case-based discussion’, Neville's trainer asked him about the levels of evidence that had prompted his guilty change of heart. Certainly Neville had not found any meta-analyses or randomised and controlled trials of Sterol-117 or red yeast, although he had to confess that he had not looked very hard. Using the drug names as keywords on Pubmed, Neville had found nothing which might excite devotees of evidence-based medicine to change their practice surrounding statin use. The trainer asked:
‘If this therapist was a doctor, would you report him to the GMC?’‘Probably,’ Neville felt very uneasy at where this question might lead.‘Do you feel that you might have chosen your words differently?’ the trainer probed.‘If he comes back with muscle cramps and myoglobinuria, who is he going to sue?’