Is the USA’s problem ours too?
Cite this as: BMJ 2012;345:e6617
Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.
Displaying 1-3 out of 3 published
A reply to: Is the USA’s problem ours too?
This feature article asks if we can relax about ‘needless overtesting, overtreating, and overdiagnosing.’ A principal concern raised is that of screening (1).
‘A stitch in time saves nine’ has long suggested that a timely effort may prevent more trouble later on. This is the mantra behind medical screening: that early diagnosis is a good thing, that it reduces suffering, and that it makes such intuitive sense that there is no need to challenge it.
Gigerenzer in his book Reckoning with risk explores screening and suggests that we consider the ‘illusion of certainty, communication of risk, and how we draw conclusions from numbers’(2).
The benefits of early diagnosis of dementia are well rehearsed, such that we have absolute agreement between medical, political, and third-sector domains. The enthusiasm for this seems to have generated an appetite for the widespread use of (largely unvalidated) cognitive ‘screening’ tests.
For cognitive screening, any certainty needs un-stitching. Forgetfulness is not an inevitable part of ageing, but there is an undeniable association of forgetfulness with age. Here screening over-simplifies, and cannot elucidate a complex set of ill-understood risks that (today) lack robust patho-physiological correlates (even upon death)(3).
What we do know, from epidemiology involving very large numbers (where pharmaceutical trials have found that current medicines are not ‘disease modifying’), is that no more than 50% of our elderly with mild amnesia progress to dementia. It is in this group that we risk a high number of false-positives (4). A diagnosis of ‘Alzheimer’s’ is a life changing diagnosis. Our elderly are generally uncomplaining and may not live long enough to refute such a diagnosis.
It is interesting that Stephen Whitehead, Chief Executive of the Association of the British Pharmaceutical Industry has chosen to respond to this article (5). The Pharmaceutical Industry has been guilty of presenting only the benefits of its products (6). This reflects the current situation with screening where benefits are represented fully but far less the costs.
(1) McCartney, M. Feature: Overtreatment: Is the USA’s problem ours too? BMJ2012;345:e6617
(2) Gigerenzer, G. Reckoning with Risk: Learning to live with uncertainty. Published 2002
(3) Reisa A. Sperlinga et al Toward defining the preclinical stages of Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease Alzheimer’s & Dementia 7 (2011) 280–292.
(4) Frances, A. DSM 5 Minor Neurocognitive Disorder. Psychology Today. 16 Feb 2012
(5) Whitehead, S. Rapid response to Overtreatment: Is the USA’s problem ours too? BMJ2012;345:e6617
(6) Goldacre, B. The drugs don’t work. The Guardian Weekly. 5 Oct 2012.
Competing interests: None declared
NHS , Forth Valley
Click to like:
I guess one would expect the chief executive of the ABPI to respond by denying everything. But it is really very condescending to Dr McCartney to suggest that her criticisms are based on mere "fashion". The evidence for malfeasance is given by the truckload in Ben Goldacre's recent book, Bad Pharma
One anecdote in McCartney's article was particularly fascinating.
Shopping last month, I was handed leaflets from a stall demanding “awareness” about restless legs, suggesting I could get treatment from my GP. The same week a drug representative tried to gain access to my practice to “educate” me on treatments.
This appears to be just another bit of disease-mongering -pushing ineffective drugs for made-up diseases. Perhaps Stephen Whitehead could tell us if it was just a coincidence?
Competing interests: None declared
UCL, Gower Street, London WC1E 6BT
Click to like:
In her article, Dr McCartney makes several disparate claims about the pharmaceutical industry. She states that the financial relations between charities and the pharmaceutical industry are ‘unclear’ and implies the latter unduly influences the day-to-day activities of the third sector. In reality, companies are required to publically declare their financial transactions with charities and the nature of their relationship by the ABPI Code of Practice. Those who fail to meet their obligations are subject to sanctions of the PMCPA – the arm’s length administrator of the Code. In addition, charities are fiercely protective of their independence and wholly committed to the patients they serve – any malign influence is therefore fiercely resisted.
Secondly, medical representatives do, entirely legally, seek to engage with clinicians to educate them on the latest available treatments. There are strict rules as to how this is conducted. But I feel it is important that clinicians are offered the chance to learn about the newest and most innovative medicines, and then exercise their own judgement about their suitability for patients.
Finally, I think there is real value in co-operation and partnership between the pharmaceutical industry and the wider health community, despite some negative preconceptions. By working together we can significantly improve health outcomes, drive innovation and save the NHS both time and money in the process. Again, this should be, and is conducted with in strict guidelines that ensures commercial interests are secondary to the needs of patients. This drive towards closer working has not been pushed by the pharmaceutical industry, but by all healthcare stakeholders. In fact earlier in the year a range of signatories, including the DH and the medical Royal Colleges, approved a series of principles for working in partnership with the life sciences sector for the good of patients.
It may be fashionable to criticise the pharmaceutical industry, but we shouldn’t be quick to criticise the good work done to help people live healthier lives.
Competing interests: Chief Executive of the Association of the British Pharmaceutical Industry
Association of the British Pharmaceutical Industry, Floor 7, Southside, 105 Victoria Street, London, SW1E 6QT
Click to like: