Sir Richard Doll receives HealthWatch award
The Fourth Annual HealthWatch Award was presented to Professor Sir Richard Doll OBE MD DSc FRS of the University of Oxford, at the HealthWatch Annual General Meeting on 14th October, in recognition of his 50 years of work at the highest level in clinical epidemiology.
It was Sir Richard who, in the 1950s, led the landmark research study of 34,000 male doctors which showed that people who smoked were significantly more likely to develop lung cancer. He has more recently studied links between vitamin D and the brittle bone condition osteoporosis.
The presentation of the HealthWatch award followed Sir Richard's fascinating talk, "Help and hindrance in epidemiology". The help, he said, came from GP's, who are highly cooperative when invited to give information for epidemiological studies. Patients are similarly willing - out of thousands of patients studied he recalled only one letter which asked how the scientists had obtained their information.
Employers, on the other hand, have a tendency to "lose" records of past employees who may have been exposed to dangerous materials such as asbestos or poison gases. He found that questions asked in the House often prompted renewed searching and the subsequent discovery of missing documents.
Fears about patient confidentiality can also hinder epidemiological research. A study which hoped to investigate the possibility of a link between road traffic accidents and tranquilising medication ran into difficulties when the police questioned the ethics of looking at details of patients' medical prescriptions.
The Department of Health have raised objections to anonymous HIV testing of blood samples routinely taken on hospital admission; and a study of the effect of natural radon emission on lung cancer was interrupted by a non-research-minded committee who insisted that they alone should be responsible for choosing the subjects for the trial.
Sir Richard's talk was beautifully delivered and provided an enjoyable and thought-provoking conclusion to this year's AGM.
The need for evidence-based medicine
At the Annual General Meeting of Health Watch at Regent College, London this year we were delighted to welcome guest speaker Professor David Sackett from the Oxford Radcliffe Hospital. The professor's compelling talk described his team's important work on the need for accurate and up-to-date information in making clinical decisions.
Doctors need new clinical information up to 100 times a week but are unlikely to receive it because their textbooks are out of date, and their journals disorganised. Yet this dearth of accurate information could influence eight important decisions every day. So began Professor David Sackett, visiting professor at the University of Oxford, when he addressed the 7th Annual General Meeting of HealthWatch on 23rd October 1995.
By questioning a group of general practitioners while they saw their patients, Professor Sackett's team identified up to 16 needs for new, clinically-important information in just half a day, of which a quarter were related to diagnosis.
However, only 30% of these information needs were met in the doctor's workplace, and most of these by asking colleagues.
The literature shows that doctors' ability to obtain the information they need is limited by out-of-date textbooks, journals that are too disorganised to be useful, and by simply not having enough time to read. Even the keenest GPs spend only one hour a week reading the medical literature, and this is clearly not enough to keep pace with therapeutic advances.
The net effect of this unfulfilled need for important new information is that it can lead to progressive declines in clinical competency. It has been shown repeatedly that there is a negative correlation between a doctors' knowledge of up to date care and the years that have elapsed since completing formal training. For example, in one study of clinical behaviour, the decision to start antihypertensive drugs was more closely linked to the number of years since medical school graduation in the doctor than to the severity of target organ damage in the patient.
It is clear, said Professor Sackett, that doctors need far readier access to clinically-important information. The problem is to distill the message buried in some 600,000 published randomised controlled trials into a form which was accessible to clinicians when they needed it, and on which they would be able to base their treatment decisions.
Critics of conventional medicine, said the professor, have claimed that fewer than 15% of medical interventions are supported by solid scientific evidence, leaving between 80 and 90% in the realms of quackery. A more reassuring picture emerged when the professor’s team reviewed the diagnoses made and interventions performed upon 121 patients admitted during April 1995 to the John Radcliffe Hospital.
He found that the vast majority - 82% - of interventions were justified on the basis of evidence-based medicine, and in 53% of all cases that evidence came from randomised controlled trials. In only 18% of cases were treatments were performed for which there was not substantial clinical evidence, and Professor Sackett found that these involved mainly non-acute disorders for which there are no known effective treatments.
The professor went on to outline how clinicians can practice evidence-based medicine for themselves as a life-long, self-directed learning process. The discipline involves:
- converting information needs into answerable questions;
- tracking down efficiently the best evidence with which to answer them;
- critically appraising that evidence for its validity and usefulness;
- applying the results and evaluating performance.
Research in Canada has shown that when equipped with these skills, graduates not only made more accurate diagnostic and management decisions, but they retained a high level of clinical competence and stayed more up to date than their traditionally trained peers as long as 15 years after graduation.
After his talk at the HealthWatch 7th Annual General Meeting Mr Nick Ross announced that Professor David Sackett was the unanimous choice of the committee for the Third Annual HealthWatch Award. Professor Sackett was presented with a handsome silver-plate comport-a dish for dessert, raised on a stem-inscribed with these words:
To Professor David Sackett in recognition of his distinguished contributions to medical research, education and the reliable assessment of treatment.
Medical journalism: triumphs and pitfalls
Geoff Watts, presenter of Radio Four's Medicine Now, is the recipient of the first annual HealthWatch Award. Here is a shortened version of the talk he gave to HealthWatch members.
The medium I work in - radio - has strengths and weaknesses. TV relies on pictures: the words are subsidiary. Print journalism does rely on words but they are mostly those of the journalists themselves, fleshed out with quotes from people whose views and ideas are being reported, disputed or analysed. But in radio this 'fleshing out with quotes' actually forms the greater part of what is broadcast. This is both the strength and the weakness of radio journalism.
It is a strength because radio journalists have the authority that comes from using a contributor's own words and voice. It also reduces the likelihood of distortion.
It is a weakness because radio journalists are more reliant on the fluency and articulacy of their interviewees. This can be a problem when dealing with complicated technical matters.
Broadcaster vs. medic
Doctors can't ignore their patients' prejudices or advocate therapies that patients don't want. Nor can broadcasters survive by making programmes that people don't want to watch or listen to. Compromises have to be made by both.
But there is a fundamental difference: doctors don't have to entertain their audiences, which are largely captive. The media do have to entertain -using that word in the sense of 'amuse and intrigue': to hold the attention.
One result is that the media do not necessarily emphasise what doctors think are the most important issues or angles. The 'responsible' journalist tempers the presentation of pure truth with enough entertainment to woo the audience; the less responsible provides nothing but entertainment - from sob stories to horror stories. But, when criticising the serious media, recall that they too have to make themselves attractive to audiences. No audience means, ultimately, no programme.
Doctors and broadcasters can fall out over the question of language, particularly when talking about matters that are technically difficult. Doctors are generally better than scientists at speaking in plain English but there is the danger of patronising the audience with talk of 'germs' and 'tummies.
Are doctors and scientists afraid to talk in ordinary language? Do they fear they won't sound important enough? Some can't seem to get away from the idea that they're talking to their peers. They're not. To talk simply and directly is not to trivialise.
Disasters and triumphs
Developments that would have been impossible without the cooperation of the media include the reduction in cot death following changes in the recommended sleeping position and the spread of knowledge about safe sex. People are now better informed about health.
Things go wrong for many reasons. There is genuine misunderstanding of the facts. Sometimes those providing the facts don't help. There is conflicting propaganda, for example, over the role of animal fats in heart disease.
Journalists occasionally decide their conclusions before they write the story. One TV production company and one particular journalist seek to champion the unorthodox ideas of Stanford University's Peter Duesberg about HIV. Provided no violence is done to the truth, and the competing claims are given a fair hearing, a partisan or unorthodox line of argument presents no problems - but it must be declared as such.
Anecdote is legitimately the basis of much journalism - to rule it out would be absurd. But, unaccompanied by the examination of more objective evidence it results in uncritical coverage of miracle cures and gee-whizz technology and a wide-eyed enthusiasm for every dubious idea dreamed up on the fringe from total allergy syndrome to the health benefits of sitting inside pyramids. It's an area in which journalists' natural scepticism can fall prey to the lure of a good story -and is a regular source of pitfalls.
Changes of points of view inside the medical establishment can lead to stories going wrong. The value of dietary fibre, the health benefits of moderate drinking and the violence induced by lowering blood cholesterol are just a few of the issues on which the research establishment has been, or is in the process of, rethinking its ideas. Changes of understanding can't be avoided - but they do create problems.
Publicity-seeking by individual doctors can generate bogus, dubious or non-stories. Motives range from self-agrandisement to bringing in private work to shroud-waving for an institution.
The practice of medicine is nothing like as international as the science on which it is (supposed to be) based. There are transatlantic differences which can be subtle and create further pitfalls for the unwary.
Finally, should medical reporters working for the lay media try to behave like editors of peer-reviewed journals? This is not practicable or desirable. The periodic failures of journalism are not so much a problem to be solved as a (sometimes unavoidable) phenomenon to be monitored, noted and kept within bounds of acceptability.
Pitfalls of medical journalism
Leading medical journalist Annabel Ferriman, winner of the 1997 HealthWatch Award, entertained members at HealthWatch's ninth Annual General Meeting in October when she explained the factors which can conspire against media reports being quite as accurate as health professionals would like them to be. Her talk is summarised here.
Pitfalls include the pressure to produce, the need to be first, the search for simplicity, the media's dislike of neutrality and commercial and political pressures. I'm going to confess that I have fallen into all of them.
The Pressure to Produce
Newspapers are not universities. They don't pay journalists to research into medical matters, fully inform themselves and then occasionally impart some of their wisdom to the British public. One day a journalist is a general reporter; the next, he or she is medical correspondent. From that day onwards, she's expected to under-stand the most complex issues and translate them into comprehensible language for the lay reader. Moreover; most of the time points are won only for disclosing information and producing copy, not for deciding that a story should not be published because it's without foundation or overblown. Experienced medical journalists who've seen dozens of breakthroughs and scares and who suggest to their news editor that the latest is not worth covering, are likely to be branded negative or stale or lazy.
For me and others who work on weeklies, or who are feature writers rather than daily journalists, the problem comes when you sell an idea to the news editor or features editor that you then cannot "stand up". When you sell it, you have usually only half-researched it and often, on further research, you discover your first impressions were wrong.
An example: I sold the idea to the medical editor of The Independent that it was a scandal that men were not being screened for prostate cancer; but discovered on further research that the issue was rather more complex. I could hardly then sell the idea that it was a good thing that we are not screening everyone for it, because that is a non-story.
This is a well-known phenomenon in journalism known as the 'one 'phone call too many'. That is, you've made a 'phone call that has knocked down your whole story. What do you do? Suppress the knowledge and pretend you never made it? Sometimes that happens. Or include the qualifying statements in paragraph 24, so that it's not too obvious that your whole story is somewhat flimsy.
The need to be first
This can result in dangerous half-truths. I have also been guilty of this: witness my piece on discovering the gene for schizophrenia. A chap at the Middlesex thought he had done so, I wrote it up and, as quite often happens, it was a false dawn. The search for simplicity.
When I first started in medical journalism, I was told by Michael O'Donnell that there were only three medical stories: the major breakthrough, the major scare and the major scandal.
The search for simplicity (usually based on the assumption that your reader has a 50-second attention span) often means that complicated stories are over-simplified to the point of nonsense.
But this need for simplicity has another side to it. Editors and readers love nothing better than the story which suggests a lot of clever scientists have been working away for years to discover the key to a healthy life; or a cure for cancer; or the answer to multiple sclerosis. And then along comes a patient, or alternative medicine practitioner, who discovers that all that scientific research was quite unnecessary, that medics had been overcomplicating things and the answer was quite simple. The media's dislike of neutrality.
Newspapers and television producers love to name the guilty men. Doctors, scientists and drug companies are often cast as the villains; the poor long-suffering patient as the hero or heroine. News editors don't tend to like stories that say: on the one hand this and on the other hand that. I was quite good at those, but they were usually put on page 10, so I didn't get many points for that.
I recently discovered that the Hammersmith were planning to offer pre-implantation diagnosis for couples carrying the breast cancer gene. I tried to write a completely neutral story, but it ended up with the headline, 'Breast cancer embryos may be culled'.
Commercial and time pressures
The fact is that most journalists are inundated with press releases every day, pushing this or that product, drug, cure, book or message. It is very easy, if you are up against a deadline, simply to reproduce a press release that you have been sent, without giving it the scrutiny that you should. I have seen press releases reproduced almost verbatim by journalists, for example a particularly idiosyncratic introduction to a Department of Health release on skin cancer was recently reproduced word for word in the Guardian. In this case, not many people would find it sinister. But it shows how easy it can be to manipulate the press.
Some PR firms spoon-feed journalists and are rewarded by column inches. I had to produce a column very quickly for the Telegraph recently, and there happened to land on my desk a long press briefing about bedwetting. It even had the magic words, 'We have a case study which could be of some interest.' I am slightly ashamed to say that I used a great deal that was in the briefing, inter-viewed the case study and banged out 1,200 words in no time. My only defence is that I had very little time, and that I did include a lot of advice about behavioural ways of tackling bedwetting, as well as the fact that there is now a good pill available.
In the light of the strong pressures working against good medical journalism, it is something of a miracle that medical coverage is as good as it is.
Leading journalist Polly Toynbee was the winner of the 1998 HealthWatch Award for her outstanding contributions in informing the public throughout her career. Ms Toynbee was unable to accept the award in person at this year's Annual General Meeting, but she prepared for us the following report of her views on issues that concern HealthWatch, ranging from health screening to bogus diagnostic techniques.
Questions were put to Ms Toynbee on HealthWatch's behalf by Chairman Professor John Garrow. He began by asking whether she believed that screening programmes involving apparently healthy people do more good than harm? She replied, "As a member of the National Screening Committee, we are bombarded with requests for national screening programmes for a huge variety of ailments, some of them utterly esoteric and rare".
There are currently several hundred haphazard screening programmes in operation, done differently or not at all in different areas, many of them of deeply dubious quality or purpose, many quite expensive. It is plainly going to take time and a lot of persuasion from the centre to get people to stop doing what they have done for a long time, where there are no clear beneficial outcomes. It is much harder to stop existing screening schemes than it is to start new ones.
We started out two years ago and have now drawn up a protocol with which to judge any proposed - or existing - screening programme.
The key principles are that the screening should be for a relatively common disease, that the process should be easy to carry out, will gain public support, a high quality should be maintainable, and that there should be a clear remedy with a definite health gain if disease is detected. The test should provide an acceptable level of false positives and negatives, and people should understand that there will always be some false positives and negatives. Every programme should have a strict quality assurance and effectiveness evaluation built into it. Cost is one element in the consideration, but it is by no means the overriding one. One of the first requests we dealt with was for prostate cancer screening. A huge head of medical pressure had built up for this procedure amongst urologists. There was also quite a strong political pressure from the small but vocal nascent men's movement who felt men should have the same access to screening as women did for breast and cervical cancer. This was the first real test of our resolve to stick by the principles we had drawn up, for prostate screening failed on several counts. The most important of these was that it was still unclear whether if prostate cancer is detected, surgical intervention makes any difference to the outcome. Prostate cancer is found in a high number of older men who will outlive their disease, and surgery can damage their quality of life without offering a clear health gain.
On the other hand, we have decided to go ahead with pilot schemes to test out the effectiveness of screening for bowel cancer. Catching it early has very clear health gains in saving lives, but the pilot will show what level of compliance it gains from the public who have to take part in a test many of the squeamish may find unacceptable. In my view, the work of the committee is very thorough, properly analytical, and well aware that the anxiety which can be caused in screening programmes - and the money wasted - can end up causing the individual and the NHS more harm than good. There is a strong push for screening for every disorder, so we regard it as most important to try to educate the medical profession and the public on the principles of screening. Our work is as public as possible and all papers are available on our own web site on the Internet.
Unvalidated methods of healthcare in conventional/alternative medicine. Is this a great evil to be rooted out? If so, how? Or should we apply caveat emptor?
Personally, I am appalled at the galloping growth in belief in 'alternative' health. Alternative only means anything which hasn't been properly subjected to clinical trials. Prince Charles keeps trying to bring together orthodox and unorthodox methods. Newspapers that thirty years ago would have had no truck with this now peddle it daily on their health pages - especially the Daily Mail - alongside articles on real health care. It is strange and alarming to me that just as more people are being educated for longer, many more doing sciences at least until the age of 16, the world seems eager to abandon basic scientific methods in favour of alchemical mumbo jumbo.
As a first step, there should be a strict edict within the NHS that no unvalidated method should ever be part of the health service. (This might not include osteopathy: for all its weird underlying beliefs, there is good evidence of its efficacy, but only in the first six weeks of back pain - not for chronic long - term conditions.) If the NHS, from the department, took a firm and public stand on this, we would at least start the debate. The Department for Education should take the same view where it is creeping into university courses - usually new universities - often with sponsorship from the makers of herbal and homoeopathic remedies.
I don't think 'caveat emptor' is enough here, when so many newspapers and magazines tell people unscientific stories about miracle cures. Perhaps all remedies, and peddlers of them, should have to tell patients clearly that their quackery has not been tested scientifically. After all, some agents such as ginseng (though goodness knows why only one or two) are specifically banned under Advertising Standards rules from claiming any health - giving properties whatever. Alas, people still take it!
When a procedure is shown to be completely bogus (e.g. iridology or applied kinesiology as a method of diagnosis) this hardly affects the popular demand for it. Why is this so? Does it matter?
Why do people cling to bogus procedures? Because they want to believe in magic and miracles. And many hate and fear doctors for phobic reasons. Some people who are well want to think themselves ill, or that they are suffering from interesting allergies, to shore up their view of themselves as more interesting people. Or simply because they are emotionally in need of feeling someone is caring for them. The one bit of good the alternative practitioners may do is to take troublesome patients off the hands of hard - pressed doctors. But obviously that has risks, since some of these patients may be ill with real diseases not at first detected.
Is there inevitably a conflict between a scientific approach to medicine and a loss of the holistic approach? Does it matter?
I don't think there's any reason for the holistic idea to be exclusive to alternative practice. We all know doctors who are good scientists and horrible to patients, and vice versa. Increasingly patients won't tolerate rude and unkind doctors, and tend to walk with their feet, if they can. Amongst younger doctors these days I'm much encouraged to hear them talk a great deal about the good they can do by treating people well, listening to them and treating them as a whole person, not as a body-part.
Clearly medical schools have become far more aware of this aspect of treatment. Also, increasing use of counsellors within GP practices can do much to help.
Will evidence - based medicine destroy the efficacy of placebo treatment in situations (e.g. multiple sclerosis) in which a good placebo is the best treatment on offer?
Evidence-based medicine is the only way forward and the government's new National Institute for Clinical Effectiveness ought to do much to weed out treatments that don't work and encourage those that do. It ought, in the end, to give people more, not less, confidence in their doctors.
The placebo effect is very powerful, and good doctors know how to use it to suit each of their patients. Some patients are scientifically minded, others just want to trust their doctor blindly. Oddly, in my experience, this has nothing to do with intelligence or education, but is an attitude of mind people adopt when faced with serious illness. Some rush out to read every book, others prefer trust and hope, or simply mentally avoid it altogether. But once we elevate the placebo effect above science, all is lost.