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Jonny Martell: What they don’t teach at medical school

29 Jan, 13 | by BMJ

Jonny MartellTomorrow I’ll go to work and among other things, prescribe drugs. I’ve been told that they work and that they’re mostly safe. There’s plenty to encourage me in believing this: whether enshrined in official guidelines or treatment protocols (or not), lots of other doctors prescribe these drugs in the same or similar patients, for the same or similar conditions. As Ben Goldacre points out in his latest book, Bad Pharma, this is an “ad hoc oral tradition.”

At medical school we learned the physiology underpinning which drugs to give for what condition. There was an elegant simplicity in the study of pharmacology—this molecule acts at this receptor, and via these signalling pathways, brings about this change. Then we were told that given classes of drugs worked for certain conditions, with the occasional reference, by a clinician or lecturer, to a particular trial to align our faith to a particular named drug.

But it turns out I don’t really know how well many of the drugs I will prescribe work, or how safe they are. Uncomfortably enough, it seems I share this dangerous ignorance with the majority of doctors. (They didn’t teach me this at medical school.) To explain why, I defer to Goldacre’s superior economy of language in the key paragraph from the introduction to his book, to which the remainder of the book is dedicated to rigorously and successfully defending:

Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques that are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don’t like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug’s true effects. Regulators see most of the trial data, but only from early on in a drug’s life, and even then they don’t give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion. In their 40 years of practice after leaving medical school, doctors hear about what works ad hoc, from sales reps, colleagues and journals. But those colleagues can be in the pay of drug companies—often undisclosed—and the journals are, too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it’s not in anyone’s financial interest to conduct any trials at all.  These are ongoing problems, and although people have claimed to fix many of them, for the most part they have failed; so all these problems persist, but worse than ever, because now people can pretend that everything is fine after all.

There wasn’t much rose in the tint of my glasses before medical school. Prior to enrollment I wrote a piece for a student journal on how doctors are as amenable to the visual appeal of pharmaceutical advertising as consumers are to other products of more obviously dubious value. But such is the volume of information to hold down and regurgitate at medical school, it’s hardly a fertile environment for critical thinking. Goldacre’s book has not just put fresh wind into the sails of my scepticism, but radically challenged what I’m actually doing on a daily basis.

When I attended a “safe prescribing” lecture recently for my hospital’s junior doctors, the irony did not escape me that prescribing the “right drug for the right patient at the right time” is hardly a guarantee of safe and effective treatment. This is all the more unsettling when this is called “best practice.” Needless to say, it didn’t seem like an appropriate forum to bring this up for discussion. So what can jobbing doctors do with any creeping sense of discomfort at the scale of our lack of knowledge and the dangers this poses to patients?

We can start by putting our signatures to All Trials. It is an online petition for governments, regulators, and research bodies to implement measures so that all trial data and methodology is available for scrutiny. The ongoing obscurantism of not just the pharmaceutical industry, but academia as well, mocks the scientific authority usually associated with the words evidence based medicine. The petition has received well deserved media coverage and is supported by amongst others, the BMJ. We should all be signing it. We might then spread the word. The only thing more scandalous than the profession’s limited knowledge as to the efficacy and safety of many of the drugs we give our patients, is our unawareness of the problem itself.

Jonny Martell is an FY1 doctor in Newcastle.

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