Views & Reviews From the Frontline

The slippery slope

BMJ 2009; 338 doi: (Published 18 March 2009) Cite this as: BMJ 2009;338:b1119
  1. Des Spence, general practitioner, Glasgow
  1. destwo{at}

    I looked down the glacier. “It’s too steep.” “Don’t be such a baby!” she retorted. She turned and skied off, pretending to suck her thumb. I knew I shouldn’t have fallen for her clever reverse psychology. I closed my eyes and pushed off, my thighs ached and barely maintained my snow plough position, but there was no going back. French children, smoking Marlboros, swished past in jeans and T shirts. In the distance my wife pretended to rock a child in her arms. But then whoosh, I went faster and faster and then exploded into a snow drift. Blood trickled from my mouth. Two Germans returned my skis and with Teutonic diplomacy rebuked me for being on the slope. Whose fault is the scar in my mouth?

    Prescribing is like skiing: so easy to start but hard to stop. It gathers pace with age and ever more risk modification. All clinics initiate their own mindless, evidence based, standard cocktail. And with the rise and rise of absolutism in medicine, those things once euphemistically called “guidelines” are now a plethora of prescribing flowcharts, vice-like in their rigidity. So, modern medicine hurtles headlong down the hill of polypharmacy—but what waits at the bottom?

    The problem is not the cost of treatment. Nor is it that drugs are so often used in a low risk population, where, like a toxic actuarial banking derivative, they have a completely unknown value. The real deal is adverse drug reactions. Besides the high proportion of hospital admissions related to medication, it has been suggested that twice as many people die from adverse drug reactions as die on our roads. With polypharmacy now seeming to be official NHS policy, and with a population that is ageing (and thus more sensitive to the adverse effects of drugs), these problems are surely set to grow.

    There is no stopping once we have started down the prescribing slope. The psychology of fear and blame means that doctors are unwilling “to take the chance” and halt the descent. Likewise, patients are reassured by the false comfort of drug treatment and are conditioned into taking drugs for life, even sometimes believing that they may die suddenly should they miss a dose.

    We need more lessons on prescribing: knowing when to start, recognising the shakiness of the supposed evidence base, and understanding the balance of risks and benefits, because often the most important intervention is knowing how and when to stop. Otherwise, when the inevitable crash comes, I know who will be to blame.


    Cite this as: BMJ 2009;338:b1119

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