Medical practitioners are rightly criticized for relying on medical representatives for updating their knowledge of new drugs and innovations. This is undesirable for two reasons. Firstly, the information provided is biased, inaccurate and often misleading. Secondly, it lays the foundations for the unethical doctor-pharma.company nexus. Sting operations have established that inducements to doctors for prescribing their products include wining and dining, gifts of cameras and air conditioners, and even trips abroad and other unmentionables. The impact of legislation like the US “Sunshine Act” is awaited; certainly the MCI code of ethics has had little effect.
Keeping abreast through journals has its own problems. The plethora of journals with variable Impact factors in every speciality and subject creates information overload and confusion. Against this background, the “Cochrane Collaboration” has proved a godsend. Named after Archie Cochrane as a tribute to his dedication to evidence based medicine, the concept took birth with his classic book “Effectiveness and Efficiency: random reflections on health services,” which highlighted our collective ignorance about the effects of health care.
Today the “Cochrane Collaboration” is a global independent network of health practitioners, researchers, patient advocates and others, covering more than 120 countries. A not-for-profit organization dedicated to separating the wheat from the chaff of medical knowledge to produce credible, health information that is free from commercial sponsorship and other conflicts of interest. They take up a question related to a specific medical procedure or practice; two or more people review all the available literature in extremely stringent and scientific methods of assessment and present a summary based on that research to establish the truth. Even unpublished reports of clinical studies are now accessed after a three year legal battle with the European Ombudsman and the European Medical Agency. The reluctance to permit such access was because unpublished studies often contain findings unpalatable to the industry. The final findings are published online in “The Cochrane Library” as “Cochrane Reviews”. These publications have an Impact Factor of 6.512 which puts them in the top ten medical publications in the world.
Against this background the editorial in the BMJ on 9th June 2014 entitled “General health checks don’t work. It’s time to let them go” by Professor Peter Gøtzsche and others from the Nordic Cochrane Centre, Copenhagen, deserves attention. The question addressed was “What are the benefits and harms of general health checks for adult populations?” The answer is summed up in the editorial: – “Doctors should not offer general health checks to their patients, and governments should abstain from introducing health check programmes”. The Danish health minister did just that when she learnt about the results of the Cochrane Review. Put quite simply, general health checkups do not confer any benefit in terms of reduced mortality. It further recommends that “Current programmes, like the one in the United Kingdom, should be abandoned”. This remains difficult because health checkups are a major money spinner for doctors as well as corporate hospitals; and offering something to a population which thinks it will help them, has popularity and feel-good value.
“Screening programmes for healthy people are justifiable only when randomized trials clearly show that benefits outweigh harms. For health checks, the trials seem to show the opposite. No discernible benefits were seen, and, like other screening tests, tend to increase over diagnosis and over treatment, with their associated side effects and psychological consequences.”
The Cochrane Review of routine mass mammography screening for breast cancer was equally revealing. For every 2000 women invited for screening throughout 10 years, 1 will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Further, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings. With substantial advances in treatment and greater breast cancer awareness since the trials were carried out, it is likely that the absolute effect of screening today is even smaller than in the original trials. Recent observational studies show more over diagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening. Further, screening will result in some women getting a cancer diagnosis even though their “cancer” would not have led to death or sickness. Because of substantial over diagnosis – women who are screened have higher rates of aggressive treatment, including increased mastectomies.
By Cochrane Review estimates, the level of overdiagnosis in countries with organized screening programmes is about 50%. Studies published in the last couple of years have failed to establish benefits of screening in Europe, and have also failed to find a decrease in the occurrence of advanced cancers. When screening doesn’t decrease advanced cancers, it cannot work and should be abandoned. Again, the problem is that it prevails over ethics because it is a money spinner.
The review states “The collective denial and misrepresentation of facts about overdiagnosis and the little benefit there is of screening, if any, coupled with the disregard of the principles for informed consent and national laws, may be the biggest ethical scandal ever in healthcare.”
Cochrane Reviews are not all gloom and doom. To quote just two examples; their reviews of the use of cholesterol lowering drugs (Statins) established that these indeed have a favorable impact on outcomes and are useful. Similarly the Cochrane Reviews of the role of bariatric surgery for obesity has shown beneficial effects that may last at least ten years.
When interviewed during the 22nd Cochrane Colloquium held in Hyderabad from September 21 to 26, 2014, Dr Gøtzsche, considered one of the sanest voices in medical fraternity dedicated to bringing evidence-based medicine, ethics and integrity back in fashion, was scathing.“Healthcare is one of the most corrupted sectors in society. In Denmark, for example, we have thousands of doctors who are on industry payroll as consultants on advisory boards. But in reality it is a soft form of bribery because if you do not behave as expected you will no longer be on the payroll. ‘Soft bribery’ such as gifts, incentives or other financial favours of pharmaceutical companies and medical manufacturers to medical professionals and the resultant conflict of interest, contributes to using expensive drugs, or at times using drugs that are not totally rational, or even using drugs instead of thinking of other evidence-based treatments”.
These are times of patients with uninformed expectations and doctors out to “treat” themselves rather than the patient. It calls for deep soul searching. As Dr. Gøtzsche says, both need to learn to say “No Thank You”.
(Dr Gladstone D’Costa is the Chairman, Accreditation Committee and member, Executive Committee, GMC)
