The Tony Blair Institute has developed a New Grand Enthusiasm. Last month’s Enthusiasm was for Artificial Intelligence (AI) in the NHS. This month’s Enthusiasm is for the population-wide general roll-out of Anti-Obesity Medication. The argument seems to be based on economics rather than pathophysiology. Because obesity is linked to so many pathological conditions – cancer, ischaemic heart disease, cerebrovascular disease, diabetes etc. – the removal of one major risk factor will help sustain a healthy population and workforce, and hence, the prosperity of the country.
Other Enthusiasms have come to light his past week. There is an Enthusiasm for chemically castrating sex offenders. First it would be voluntary, but its champions are not ruling out making it compulsory. Nothing is off the table. When politicians are “minded” to go one step further like this, it usually means they are flying a kite; or sticking a wet finger in the air to see which way the wind of public opinion is blowing. I seem to recall that Alan Turing, now a great hero of the proponents of AI, once himself deemed to be a sex offender, was chemically castrated. Was it voluntary or compulsory? Or was it offered as an alternative to imprisonment? In other words, was he coerced? He took his own life.
Another Enthusiasm is to create separate acute assessment units for patients with issues of mental health. The “chaos” of “A & E” is not helpful to them.
These, and other similar initiatives share two common features. First, they are public health initiatives, based on perceived crises, pandemics of morbid obesity, sexual abuse, and poor mental health. Public health initiatives are usually preventative measures, designed to protect whole populations by lowering a relative risk. They are not, by and large, “patient focused”. Secondly, they tend not to be initiated by health care professionals, but rather by groups, factions, and vested interests which seek to organise and shape the societal Gestalt, politicians, Think Tanks, QANGOS, and various allied “Medinfluencers”. Doctors and nurses are often the last to know what the latest societal manipulation is going to be, because they are too busy seeing patients. Patients consult them; but the medinfluencers don’t.
I certainly don’t mean to knock public health initiatives across the board. Vaccination, after all, has been the most successful public health initiative of all. We have known of its overriding beneficence for hundreds of years, ever since medieval villagers got their children to climb into bed with a child who had cowpox, because it protected them – nobody knew why – against smallpox.
But it seems to me that, over the course of the new millennium, the focus in health is shifting from the individual, to the populace at large. Everybody is at risk of something; everybody is on a spectrum of disease. I first started noticing this when patients were referred to hospital, either acutely or via outpatients, with symptoms suggestive of cardiovascular disease – chest pain, shortness of breath, exercise intolerance. The tests – CXR, ECG, treadmill test, echo, bloods – would all be normal. But the patient would still come home on a swag of preventative medication – statins, antihypertensives, aspirin… The next development was the polypill. Just put everybody on that swag of preventative medication even if they are entirely well. Why not? These drugs are well tolerated (mostly; so, for that matter, are anti-obesity drugs, apparently). The notion of normality, of “normal values”, became eroded. Traditionally, a blood pressure of 140/90 was regarded as “the upper limit of normal”. No longer. 130/80? Too high. Drive it down as low as you can (without keeling over). Same with cholesterol. Don’t even bother measuring it. Just take the statin. “Fire and forget.” New diagnoses crept into the medical lexicon – “pre-hypertension”, “pre-diabetes”. Something similar has happened in mental health. Everybody is on the spectrum of something
It’s hard to overestimate the extent to which this prevailing trend is completely alien to the way I was taught as a medical student in the 1970s. Then, the whole structure of medical practice was based on the concept of diagnosis. The medical consultation was designed, and systematically conducted, in order to reach a clear, and accurate, diagnosis. It was based fundamentally on the elucidation of a very careful history, taken from the patient. That was paramount. The patient was not thought of as a cog in a huge, national industrial wheel, that had to be kept turning, but rather as a unique individual.
The history was followed by the physical examination. We were taught to elicit physical “signs”, evidence of pathological processes. We were encouraged to be decisive about the presence, or absence, of signs. A cardiac murmur, a palpable abdominal mass, a neurological deficit – either it was present, or it was absent.
The history and the examination predicated, perhaps, some highly specific and targeted radiological and laboratory investigations, designed to confirm, or repudiate, the formulation of a pathophysiological process. The confirmation of a diagnosis was the solid bedrock of therapeutics: treatment, and patient management.
All this has been eroded. Why bother talking to the patient when you can simply run them through an algorithm? Why bother examining them, when you can order up a swag of tests? (I remember hearing a GP give a presentation in which he said, somewhat boastfully and without a trace of irony, that he didn’t own a stethoscope. It was the worst medical talk I ever heard in my life.) But the trouble with practising Blunderbuss Medicine is that soon you are inundated with an entire population which has been persuaded that it is unwell. No wonder “A & E” is described as “chaotic”. We need to ask ourselves: why are so many people overweight? Why are so many people miserable? My theory, on both counts, is that it is because they have been encouraged by the masters of the universe to spend their entire lives, both professionally and at leisure, in front of computer screens. I have no doubt that for some patients, some weight reduction drugs have a place. But for the most part, and for most of us, millions of people in the population, we don’t need them. So Log off, and go and climb a hill. It’s cheaper, healthier, and much better fun.
jamescalumcampbell 