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Another thoughtful and insightful editorial involving patient and doctor relationships
“but we also need innovators with the energy and optimism to try new ways to do things”.
This used to happen (Dr James LeFanu - “The Rise and Fall of Modern Medicine”) and in my personal experience. Penicillin and cortisol are examples.
Now the pharmaceutical companies tend to dominate research which is based on what they consider to be potentially profitable; a fact that is acknowledged by some researchers and clinicians.
All too often, evidence based medicine has been reduced to the enactment of bureaucratic and authoritarian "recommendations" that are based on population data and enforced through payment for performance contracts
This is indeed true. One might reasonably add the threat of GMC action or legal suit. Recommendations are based on data from specific conditions that apply to a tiny fraction of the total population and then are applied to the whole population. An example is salt; many studies1 have shown that reducing salt intake has a tiny effect on reducing blood pressure in the healthy and indeed those on higher salt intakes live longer. On the other hand those intolerant to salt or with serious kidney problems do benefit but this is not an excuse for frightening and coercing public. Another example is of course cholesterol where the WHO-BHF data shows that optimal levels for the majority is as follows:
Estimated lowest mortality rates for TC blood levels
All Cause mortality 222 mg/dl 5.75 mmol/L
Non-communicable disease 210 mg/dl 5.49 mmol/L
Cardiac Disease 208 mg/dl 5.44 mmol/L http://www.heartstats.org/documents/download.asp?nodeib=6797 This URL no longer exists? WHY hide data?
Now on https://renegadewellness.files.wordpress.com/2011/02/cholesterol-mortali... http://healthcorrelator.blogspot.co.uk/2009/12/total-cholesterol-and-car...
They say that usable decision aids should now be seen as one of the most important end products for evidence based medicine
Such decision based should include the true probability of the incidence in the case of healthy individuals and the probability of “no benefit” rather than treating the healthy on the basis of the inflated relative rate of those already suffering the condition.
This alone might do much to restore GPs’ sense of themselves as autonomous professionals rather than overworked and undervalued state
As a patient and a vet, frankly I do not understand why GPs are treated as if they were students and dictated to by their professors/guidelines. Surely GPs should be allowed to do what they have been trained to do rather than being dominated by the threat of the GMC or legal suit if they do not follow the guidelines explicitly. Poldeman is a case in point - one wonders to what extent other guidelines are flawed. Keys and his insistence on Hicarb/Lofat is another case in point. Today sugar is a “no go” but Yudkin demonstrated this some 50 years ago and starch is simply a string of glucose molecules - not ideal for those suffering a surfeit of glucose one would think.
JZ Miller, SA Daugherty, MH Weinberger, CE Grim, JC Christian and CL Lang. Hypertension 1983, 5:790-795 Blood pressure response to dietary sodium restriction in normotensive adults Cochrane Database Syst Rev. 2003;(1):CD004022.
The magnitude of the effect in Caucasians with normal blood pressure does not warrant a general recommendation to reduce sodium intake.
Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH. Hypertension. 1995 Jun;25(6):1144-52. Low urinary sodium is associated with greater risk of myocardial infarction among treated hypertensive men. The frequency of heart attacks was LOWEST in the group with the highest salt intake
Re: Old problems, new models
Another thoughtful and insightful editorial involving patient and doctor relationships
“but we also need innovators with the energy and optimism to try new ways to do things”.
This used to happen (Dr James LeFanu - “The Rise and Fall of Modern Medicine”) and in my personal experience. Penicillin and cortisol are examples.
Now the pharmaceutical companies tend to dominate research which is based on what they consider to be potentially profitable; a fact that is acknowledged by some researchers and clinicians.
All too often, evidence based medicine has been reduced to the enactment of bureaucratic and authoritarian "recommendations" that are based on population data and enforced through payment for performance contracts
This is indeed true. One might reasonably add the threat of GMC action or legal suit. Recommendations are based on data from specific conditions that apply to a tiny fraction of the total population and then are applied to the whole population. An example is salt; many studies1 have shown that reducing salt intake has a tiny effect on reducing blood pressure in the healthy and indeed those on higher salt intakes live longer. On the other hand those intolerant to salt or with serious kidney problems do benefit but this is not an excuse for frightening and coercing public. Another example is of course cholesterol where the WHO-BHF data shows that optimal levels for the majority is as follows:
Estimated lowest mortality rates for TC blood levels
All Cause mortality 222 mg/dl 5.75 mmol/L
Non-communicable disease 210 mg/dl 5.49 mmol/L
Cardiac Disease 208 mg/dl 5.44 mmol/L
http://www.heartstats.org/documents/download.asp?nodeib=6797 This URL no longer exists? WHY hide data?
Now on https://renegadewellness.files.wordpress.com/2011/02/cholesterol-mortali...
http://healthcorrelator.blogspot.co.uk/2009/12/total-cholesterol-and-car...
They say that usable decision aids should now be seen as one of the most important end products for evidence based medicine
Such decision based should include the true probability of the incidence in the case of healthy individuals and the probability of “no benefit” rather than treating the healthy on the basis of the inflated relative rate of those already suffering the condition.
This alone might do much to restore GPs’ sense of themselves as autonomous professionals rather than overworked and undervalued state
As a patient and a vet, frankly I do not understand why GPs are treated as if they were students and dictated to by their professors/guidelines. Surely GPs should be allowed to do what they have been trained to do rather than being dominated by the threat of the GMC or legal suit if they do not follow the guidelines explicitly. Poldeman is a case in point - one wonders to what extent other guidelines are flawed. Keys and his insistence on Hicarb/Lofat is another case in point. Today sugar is a “no go” but Yudkin demonstrated this some 50 years ago and starch is simply a string of glucose molecules - not ideal for those suffering a surfeit of glucose one would think.
JZ Miller, SA Daugherty, MH Weinberger, CE Grim, JC Christian and CL Lang. Hypertension 1983, 5:790-795 Blood pressure response to dietary sodium restriction in normotensive adults Cochrane Database Syst Rev. 2003;(1):CD004022.
The magnitude of the effect in Caucasians with normal blood pressure does not warrant a general recommendation to reduce sodium intake.
Alderman MH, Madhavan S, Cohen H, Sealey JE, Laragh JH. Hypertension. 1995 Jun;25(6):1144-52. Low urinary sodium is associated with greater risk of myocardial infarction among treated hypertensive men. The frequency of heart attacks was LOWEST in the group with the highest salt intake
Competing interests: No competing interests