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EDITOR'S CHOICE: Fiona Godlee Less medicine is more BMJ 2009; 338: b2561 [Full text]

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more or less

L Sam Lewis   (28 June 2009)

Medicalisation

Rahul Shetty   (29 June 2009)

Less means more: 100% QOF achievement may not be ideal

Jonathan D Sleath   (29 June 2009)

Man's Inhumanity To Man

Dr. Herbert H. Nehrlich   (1 July 2009)

Even less could be too much!

BM Hegde   (2 July 2009)

Re: Even less could be too much!

Raymond G Holder   (5 July 2009)

Reply to Raymond Holder

Richard Bartley   (6 July 2009)

Reduction in breast cancer mortality from mammographic screening

Nicholas J Wald, Malcolm R Law, Stephen W Duffy   (10 July 2009)

Uncertainty and numbers

Hazel Thornton   (11 July 2009)

more or less 28 June 2009
L Sam Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ Send response to journal: Re: more or less	Fiona Godlee ably manages a difficult editorial balancing act by recognising that ‘less is more’ on occasion. Medicalisation can be bad for your health, and we should be cautious, as hinted by “although screening for abdominal aortic aneurysm seems to be effective and, for the moment in the UK, cost effective”. I find myself in full agreement with Iona Heath, in her informed decision to say no to Breast Screening. I ask myself should I have an Abdominal Aortic Aneurysm (AAA) screen ? Buxton’s editorial on AAA screening ably discusses the cost-effective modelling. But claiming that it ‘remains effective’ is a narrow viewpoint worthy of Iona’s attention. “A 42% relative risk reduction in mortality related to abdominal aortic aneurysm (absolute risk reduction from 0.33% to 0.19%)” sounds impressive, until you ask how many were harmed or died as a result of interventions, and how many people were screened and falsely reassured ? By stating the benefit but not the risk of harm, I don’t get the necessary information on which I can make an informed decision, despite a subliminal hint “that there may be a small increase in net deaths in the short term.” Editorial policy should require the statement of benefits in ABSOLUTE as well as relative terms, and in the interest of balance and fairness, for the risks and harms to also be stated. Competing interests: None declared
Medicalisation 29 June 2009
Rahul Shetty, Surgeon Canada,G1V 4G5 Send response to journal: Re: Medicalisation	Fiona Godlee in her editorial Less medicine is more aptly depicts the current state of medical management. Increased emphasis on diagnosis, and also increased reliance on various investigations, will not necessarily translate on to better management of patients. The overwelheming growth of new diagnosis for treatment of diseases forces an increased burden on the health care system worldwide. It is imperative that in future medicine would include more preventive steps in order to make patient dependent on medicine less. Competing interests: None declared
Less means more: 100% QOF achievement may not be ideal 29 June 2009
Jonathan D Sleath, General Practitioner Kingstone Surgery, Hereford. HR2 9HN. Send response to journal: Re: Less means more: 100% QOF achievement may not be ideal	I believe that the GP’s Quality and Outcomes Framework may be another example where less medicine means more [1]. We are now entering the season when once again practices can look forward to being ranked according to their QOF scores. At our LMC meeting last week the PCT Director of Commissioning produced a list of the 2008/9 QOF achievement points per practice and congratulated those reaching 100%. It is not entirely sour grapes to say that my practice was not one of those, and that whilst 100% represents a triumph of income generation I do not believe it is what we should aspire to. Other systems exist where reaching 100% is not the ideal, for example bed occupancy in an acute hospital, which which if completely full would be closed to emergency admissions. There are many aspects of the QOF targets that GPs feel uneasy about. The rules are cumbersome, slow to change to reflect new ideas, and fail to acknowledge the uncertainty and diversity of evolving opinion. For example this year we have already had articles in the BMJ questioning the wisdom of intensive lowering of HbA1c levels in Type 2 diabetics [2], and the routine monitoring of blood pressure in hypertensives [3]. Yet both of these are enshrined in the current QOF rules. Whilst there are many good aspects to the current QOF framework, too rigid an adherence and aiming for 100% suggests to me that we have sold our souls to the devil, and sacrified yet more of our professional judgement. We should aim to create a culture in which it is accepted that the higher the QOF score does not always mean the better the clinical care. 1. Fiona Godlee. Less medicine is more. BMJ 2009;338:b2561 2. Richard Lehman, Harlan M Krumholz. Tight control of blood glucose in long standing type 2 diabetes. BMJ 2009;338:b800 3. Richard J McManus, Jonathan Mant. Management of blood pressure in primary care. BMJ 2009;338:b940 Competing interests: None declared
Man's Inhumanity To Man 1 July 2009
Dr. Herbert H. Nehrlich, Private Practice Bribie Island Australia Send response to journal: Re: Man's Inhumanity To Man	I fully agree with the concept that less medicine can be more and that it most often would be. The way to achieve this is another matter, something bordering on the impossible in modern society. There are tremendous forces in place that are unleashed the moment the system perceives the presence of other Gods (such as Alternative Healers)or (heaven forbid) open disillusionment and revolt against ineffective disease mongering. One hears the word "patient compliance" everywhere, followed by the remedy for the lack of such which goes by the name of patient education. In reality, most of these efforts are scaremongering tactics dressed up as caring and social conscience. Far too much money can be made from the business with the sick and this again can be further boosted by the invention of new "illnesses" and by mass screening. There is a way to reduce the dependency of the masses on medication and intervention, that way is to take the profit out of the business with disease. Make Medical Practice into the altruistic profession it once was and is meant to be, where an educated fool helps the unfortunate. Yes, pay the helper and grant the sick person the right to receive either free or very affordable care when sickness strikes but pay them as you would the ordinary schoolteacher or the candlestickmaker. Teach all second grade children the difference between relative and absolute risk and rename Big Pharma by deleting the "p". It is the love of money that has turned into an obsession to get rich at the expense of the suffering of others that is the pillar underpinning the disgraceful way in which the sick are treated in almost all regions of the world. Here again, America is the clear leader. A shame isn't it, a real shame. Competing interests: None declared
Even less could be too much! 2 July 2009
BM Hegde, Editor in Chief, Journal of the Science of Healing Outcomes. Mangalore-575 004. Send response to journal: Re: Even less could be too much!	Dear Fiona Godlee, Western medicine has been suffering from many ailments. Organ based specializations have taken medicine to the valley of illogcalism while the Mendelian inheritance has added to its vows! There is a new energy anatomy of the human body. Because of the varying rates of cellular turnover, some organs might predominantly show symptoms in some diseases while the other organs are also affected to a lesser extent. 450 year old Vaselius’s organ based anatomy (which is useful in surgery) and Mendel’s laws of inheritance need a re-look in the light of the newer knowledge that human body is but a bundle of jumping leptons, which are the same irrespective of the organ in the body. Any disease is but an altered state of energy pattern that needs to be set right for healing. Significant part of the DNA material is left outside the nucleus in evolution of a unicellular organism. This has vital part to play in inheritance, disease states and healing. They are the mitochondrial mtDNAs as opposed to the Mendelian nDNAs. (While)“Western pharmacology, which requires a known drug target around which the drug is developed, traditional Asian pharmaceuticals were discovered by trial and error, on the basis of what made the patient better. This trial-and-error approach to drug development is inefficient but it is paradigm blind. If mitochondrial dysfunction is as important a factor in diseases, as proposed in this essay, then Asian herbal medications should be as likely to have targeted a mitochondrial energetic function as a tissue-specific structural function. If so, we might be able to identify active mitochondrial backbone drugs by screening traditional Asian therapeutics for those that modulate mitochondrial function,” writes Smith. (1) Significant work in this area has already been done using a new Chip, the MITOCHIP, with regard to Asian herbal medicines. These medicines are not alien to the human system as both are holistic in their approach to health and healing. Every chemical molecule (the drug) has the drawback of damaging the hardware (mitochondria etc) inside every cell while we need to target the software, which resides in the thousands of proteins that form two energy systems-low and high, which together supply the electromagnetic energy from the sun; transducing that energy in the bargain for running all the cells in the human system. Therefore, even very, very less of the menacing chemical molecules is too much to bear! We need to think laterally to progress. Energy medicine, using known and subtle energies, has come into main stream science these days. Let us advice Pharmaceutical lords that there is more money in that area and less harm to mankind! Earlier they realise it, the better for them and the hapless patients, as otherwise the informed public will hound them out sooner than later when the drug menace becomes common knowledge, thanks to Google’s Open University. “If the whole material medica could be sunk to the bottom of the seas, it will be that much good for mankind, and that much worse for the fishes.” What a prophetic statement by that brilliant brain, Oliver Wendell Holmes? Yours ever, bmhegde Reference: 1) Smith, J. V., Burdick A. J., Golik .P, Khan I, Wallace D. et al., Anti-apoptotic properties of Ginkgo biloba extract EGb 761 in differentiated PC12 cells. Cell. Mol. Biol. 2002; 48: 699–707. Competing interests: None declared
Re: Even less could be too much! 5 July 2009
Raymond G Holder, Long retired engineer BH9 3NF Send response to journal: Re: Re: Even less could be too much!	B M Hegde’s Response :” Even Less could be too much” interested me because, fundamentally, I have thought that current Western medicine and its many specialties appear to be based on each organ as a “lump” of a particular form of tissue, whose operation is unique to that organ, and somehow able to be considered independently from the whole energy supply arrangements for the totality of the body. The concept of virtually all energy having only one, but universally found and necessary source, the mitochondria, seems to be considered as just a biological fact, not to be considered in dealing with the hardware of individual body parts and their functions. Perhaps it is the very minute size of the individual mitochondrion, about one thousandth of a millimetre, that people find the fact of its absolute necessity incomprehensible, but as millions populate the whole body, they form the diffused power source without which life cannot exist. Mitochondria have a separate DNA from the rest of the body, mainly derived only from the mother. This is said to be so because the male mitochondrial DNA is contained in the tail of the sperm, which falls off outside the egg at fertilisation. Errors in its composition are thus more likely not to be corrected, and mitochondrial mutations are readily triggered off by damaging drug side effects. Multiple schelerosis, and a statin related form of ALS are now thought to be due to damage to the cytochrome complex in the mitochondria, while Coenzyme Q10 deficiency leaves the transfer of electrons between complexes 1 and 2 and on to the cytochrome without a connecting path. Outside the mitochondria, carnitine is necessary to transport fat as fuel through the membrane to get to the ATP producing process inside. Carnitine has enemies both in genetic make up and from drugs and illnesses, e.g. new born infants may die from genetic carnitine deficiency, dialysis patients need supplementation as it is lost in the process, post polio syndrome patients have a greater need of it due to muscle metabolic need changes, and those with statin damage seem to lose their supply. Recent research at Maryland on carnitine transporters has found about 50 commonly used drugs, statins, some anti-biotics, diltiazem, and many others which inhibit them, so depriving the vital processes of energy. Drugs are often very blunt instruments, I am now taking furosemide, which, while it is preventing me from dying has had some very bad unintended effects, and does nothing to address the root cause of the problem, and places severe restrictions on the few things I can now do. But statins damaged my Q10 production, with reduction of energy supply to my heart, coupled with carnitine lack from Post Polio, a dangerous combination. Several other drugs, notably, but not exclusively, beta blockers, also sabotage Q10 production, so blood pressure treatment by beta blocker has the ability to reduce heart muscle strength and thus cause further pumping inefficiency and adding to the cause of the problem anyway. I perceive a reluctance of some specialisms to lose what they believe to be their property, post polio patients being told by neurologists that their problems don’t exist. I told Sorensen et al,of the Mayo clinic, whose paper said that Post polio did not exist, because neurological tests showed no greater nerve degeneration than that in non polio people, that they were looking in the wrong place, it is no longer a neurological problem, but one of metabolism. ME/CFS has been taken over by psychiatrists, even at NICE. I found a Rapid Response by John Tovey stated he had found Chlamydia pneumoniae infection inside body cells, feeding upon the cell’s energy sources, only responding to sustained and varied anti biotic treatment, a finding which has a much more plausible view of the way in which it occurs, but who is to work on this possibility? Certainly not psychiatry. Cardiology treats heart problems as only muscle and electrical problems, I was told my heart muscle was stiff, solely from a heart scan, but that is only an interpretation of the heart’s muscle movement as seen, it is much more likely that its energy supply was low, insufficient at that time to allow strong action. Metabolic cardiology is now being practiced in various places, by conventionally trained cardiologists, with considerable success, using a minimum of invasive procedures, and fewer drugs. Competing interests: Badly statin damaged patient
Reply to Raymond Holder 6 July 2009
Richard Bartley, Physiotherapist Wales Send response to journal: Re: Reply to Raymond Holder	I don't doubt the theory that intracellular/mitochondrial dismetabolism may be the root cause of a range of common conditions, but how much damage are we talking about? A signficiant amount, or perhaps not nearly enough to disavow the potential benefits of statins, betablockers etc.? Competing interests: None declared
Reduction in breast cancer mortality from mammographic screening 10 July 2009
Nicholas J Wald, Director, Wolfson Institute of Preventive Medicine Barts and the London School of Medicine and Dentistry, Malcolm R Law, Stephen W Duffy Send response to journal: Re: Reduction in breast cancer mortality from mammographic screening	Fiona Godlee[1] concludes that our silence gives assent to Peter Gøtzsche’s views[2] on the magnitude of the effect of mammographic screening in reducing breast cancer mortality. It does not. We disagree with him, and did not respond because Gøtzsche’s responses[3,4] were offensive with their unjustified allegations of incompetence, bias, and conflicts of interest. Our letters stand.[5,6] There is no need for the complexity that Gøtzsche introduces. The meta-analysis of randomized trials performed in 1993 on behalf of the European Society of Mastology[7] showed that the reduction in breast cancer mortality among women invited for screening in women aged 50-74 was 24% (relative risk 0.76, 95% confidence interval 0.67-0.87), a result that has been widely accepted. This intention-to-treat analysis avoids selection bias (that is, bias due to a difference in the risk of breast cancer death in women who decline screening and in those who accept it) but at the cost of diluting the true estimate of breast cancer mortality reduction because not all women invited for screening were screened – about 22% declined the invitation but were still included in the analysis as if they had been. The true “on treatment” effect of screening must, therefore, have been greater than the 24% reduction and would have been 31% assuming no selection bias. In the absence of evidence of strong selection bias, a reasonable estimate of the reduction in breast cancer death from screening is, therefore, about 30%. It is simple to apply the 30% reduction in risk to an absolute background risk of breast cancer death, which we did in our letter.5 To put it even more simply, in the absence of screening about 5% women die of breast cancer. If screening is performed over about 20 years from age 50 this will have an impact on about 60% of the breast cancer deaths because this is the proportion that die between ages 55-75 (56% in 1988 before systematic screening was introduced), given that screening will reduce deaths a few years later. This represents about 3% of all deaths in women (60% of 5%) which will be reduced by about 30% from screening and treatment, that is, an absolute risk reduction of 1% (30% of 3%) over about 20 years, or about 0.5% over 10 years. This is close to our estimate of 0.6% but higher than Gøtzsche’s estimate of 0.05%. The key estimate in the calculation here is the 30% breast cancer mortality reduction from the trials in women who are screened; the other numbers needed are generally available. There is adequate evidence to show that the estimate of about 30% is likely to be correct, and it is the best estimate we have. Whatever the costs of screening (human and financial), the fact that breast cancer screening saves lives should not be ignored. It can be summarized as follows: In 100 women aged about 50, three would die of breast cancer in the next 20 years if they were not screened, but if they were screened, two would die and one would be saved, a reduction in risk of about 30%. It is not necessary to be rude or imply improper motives or bias from conflict of interest in debates such as this. We believe our estimates are correct, simple to derive, and defendable, while those of Gøtzsche are not. Others can reach their own judgments. If we do not respond to another response by Gøtzsche, particularly if written in the same tone as previous ones, readers should not conclude that our silence means we agree. Nicholas J Wald, Malcolm R Law, Stephen W Duffy Wolfson Institute of Preventive Medicine Barts and the London School of Medicine and Dentistry References 1. Godlee F. Less medicine is more. BMJ 2009;338:b2561 2. Gøtzsche P, Hartling OJ, Nielsen M, Brodersen J, Jørgensen KJ. Breast screening: the facts – or maybe not. BMJ 2009;338:b86 3. Gøtzsche P, Hartling OJ, Nielsen M, Brodersen J, Jørgensen KJ. Estimate of Breast screening benefit was 6 times too large. BMJ 2009. (Rapid response 3 March 2009) 4. Gøtzsche P, Jørgensen KJ. Stephen Duffy’s claims on the benefits and harms of breast screening are seriously wrong. BMJ 2009. (Rapid response 1 May 2009) 5. Wald NJ, Law MR. Response to Gøtzsche. BMJ 2009. (Rapid response 27 February 2009) 6. Duffy SW. Estimate of breast screening benefit was 6 times too large. BMJ 2009 (Rapid response 29 March 2009) 7. Wald NJ, Chamberlain J, Hackshaw A (on behalf of the Evaluation Committee). Report of the European Society for Mastology Breast Cancer Screening Evaluation Committee. The Breast 1993;2:209-216 Competing interests: None declared
Uncertainty and numbers 11 July 2009
Hazel Thornton, Honorary Visiting Fellow, Department of Health Sciences, University of Leicester "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA Send response to journal: Re: Uncertainty and numbers	“Whatever the costs of screening (human and financial), the fact that breast cancer screening saves lives should not be ignored. It can be summarized as follows: In 100 women aged about 50, three would die of breast cancer in the next 20 years if they were not screened, but if they were screened, two would die and one would be saved, a reduction in risk of about 30%.” [1] Two brief comments: firstly, it must `not be ignored` that breast cancer screening causes more harm than benefit. (The ratio depends on various factors that should be taken into account when making calculations.) The NHS Breast Screening Programme has a responsibility to tell women about harms when they invite them. Currently, they do not. [2] Also, is it right that an NHS organisation should knowingly cause harm in a population, thereby flouting the Hippocratic principle? Secondly, `ordinary` readers need transparency in communicating numbers if they are to be able to follow the argument. [3] People expect certainty. [4] It is not to be had - in tests that are “not 100% accurate” [2]; in reading mammograms (both diagnostic and screening); in determining pathology; in calculating ratios of benefit to harm; etc. We must work to reduce uncertainties. [1]Wald NJ, Law MR, Duffy SW. Reduction in breast cancer mortality from breast cancer screening. bmj.com rapid response 10 July 2009. [2] NHS Breast Screening Programme. Breast Screening: The Facts. Revised 2009. [3] Editorial: Imogen Evans, Hazel Thornton. Transparency in numbers. The dangers of statistical illiteracy. Journal of the Royal Society of Medicine. In press. 7th July 2009. [4] Lancet Refractor. Uncertainty. Lancet 2001; 358:2090 Competing interests: None declared