10 Sep, 14 | by Toby Hillman
A famous quote from the eminnet paediatrician Sir Cyril Chantler was published in the BMJ in 1998:
“Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous.”
As medicine progresses, it is worth keeping this in mind. The complexity of modern medicine is one of the challenges that has led to a deal of dissolusionment with with Evidence Based Medicine movement – and the recent calls for renewal of the principles behind EBM from Trish Greenhalgh and colleagues highlights the importance of relating evidence to the individual being cared for, rather than just the guidelines that relate to the ‘perfect’ patient.
A paper recently published in the PMJ on the risk factors and features of non-variceal upper GI bleeding in inpatients, and its relation to antithrombotic drugs made me think again about my own practice, and probably the practice of a great many colleagues of mine up and down the country.
The paper examined cases of NVGIB at the University Hospital Crosshouse in South West Scotland. The investigators looked at all cases of NVGIB in their hospital over a period of 12 months, to understand the risk factors associated with this condition, and in particular the role that antithrombotic drugs play. The investigators split the patients into two groups – those developing NVGIB as inpatients, and those presenting to hospital with bleeding symptoms and signs. The data were collected as part of an ongoing prospective examination of the epidemiology and management of upper GI bleeding.
The two groups showed some interesting differences – those developing bleeds as inpatients tended to be older, more likely to be female, were on more antithrombotic medication (particularly non-aspirin drugs), had more cardiovascular disease, and have higher Rockall scores than those presenting to hospital with bleeding.
The authors conclude that secondary care physicians looking after the older female population that suffers with cardiovascular disease should consider more strongly the need for prophylactic anti-ulcer therapy.
This advice would seem to be borne out by the evidence, and is a practical solution. The paper did not examine the appropriateness of the use of anti-thrombotics in the first place – it would probably be beyond the scope of an observational study such as this.
However, as I read the paper and the conclusion – that more medicine is probably where the answer to this conundrum lies, I wondered how many of these elderly ladies derived significant benefit from the additional anti-thrombotic medicines they were prescribed. This is pure supposition, but I wonder how many were given their new drugs in response to an admitting complaint that perhaps didn’t completely justify the use of powerful, complex, dangerous medicines?
I can easily imagine a patient presenting with some atypical sounding chest pain, some breathlessness accompanying it, who is written up for “ACS protocol” medications on admission, and spends a little time awaiting investigations to rule in or out significant cardiac disease. After a couple of days the patient may develop their bleeding complication, and on the story goes. The patient has probably had great protocolised medicine, and has had their risk factors assessed, and their symtpoms noted and reacted to, but perhaps their whole situation hasn’t been weighed up. For example, the application of the “ACS protocol” to patients who don’t fit the evidence base (eg those with a history, but without ECG changes or enzyme elevation were excluded from the CURE trial after the first 3000 patients) may not be great evidence based medicine – but it is often a protocol applied to patients presenting with cardiac sounding chest pain to the acute medical unit, prior to the full information, and therefore full estimation of benefits and harms can be considered.
When we then consider the solution to this conundrum seems to be to add in further medications to offset the harms of those potentially initiated on a less than optimal basis, I wonder if we aren’t just ending up chasing our tails.
Maybe we need to come back to Sir Cyril again, and finish off his quote:
“Medicine used to be simple, ineffective, and relatively safe. It is now complex, effective, and potentially dangerous. The mystical authority of the doctor used to be essential for practice. Now we need to be open and work in partnership with our colleagues in health care and with our patients.”
It is the being open, and working in partnership with our patients that will deliver the better results. Lets be honest – if a story doesn’t sound quite like a high-risk ACS then perhaps we could wait a bit for the evidence to back up our proposed management plan, and avoid overtreating, over medicating, and harming those at highest risk of both ‘natural’ and ‘iatrogenic’ disease.
Risks identified – additional drugs
Solution proposed – more drugs
Link to the NOACs and the bleeding risks associated.
Importance of balance.
Is this a cognitive bias that needs addressing – always adding.