For reasons that I have previously written about, I have to have my blood pressure, cholesterol, and blood glucose checked every year. These measurements have always been normal. Of these, I don’t know a single one of my cholesterol measurements. Not one. In fact, one of my previous GPs asked me if I wanted to know what my cholesterol measurement was. I remember smiling at her and saying that I didn’t, because even if it was elevated my risk would still be low. She nodded and smiled back. I don’t know whether she thought I was eccentric but she didn’t pursue the matter.
Even as an ex-smoker at the age of around 40, with a normal blood pressure, and almost reasonable BMI, there is just simply no way that a raised cholesterol level can cause me to be at increased risk of a cardiovascular event. I am sad enough to have tried putting my figures into a risk calculator. Even a total cholesterol: HDL cholesterol ratio of 10 gives me a risk of 4.4%, which is way below any treatment threshold with statins, although it would probably warrant a referral to the lipid clinic.
When discussing statins with patients, I sometime use the “Extension of Life” or “Prediction of Mortality” models proposed by Støvring et al and tested recently. They used large databases to come up with predictions of how much life expectancy can be extended by treatment with statins. If I apply the tables to myself then, depending on what my total cholesterol is, I can probably expect on average to live to the age of 78 or so—another 38 years. If I was to start a statin then my life expectancy would, on average, be extended by six months. In other words, I would extend my life by 1.3%. Patients who realise the “minimalitude” (is that the opposite of magnitude?) of the effect of statins on their overall mortality—for that is their purpose after all—are then less likely to want to go on them.
So why do I bother getting my cholesterol checked?
It’s certainly not my idea. Patients with my kind of condition are more likely to suffer from cardiovascular disease. My GP is paid therefore to check my cholesterol every year. He would be penalised if I didn’t turn up. In the past, he would worry about exception coding me, marking me out as a conscientious objector, because high levels of exceptions can lead to investigations and withdrawal of funds.
This is what tick box medicine is; this is what tick box medicine feels like. I was taught as a junior doctor to only do tests whose results would alter my future management. Testing my cholesterol repeatedly will only alter my GP’s future remuneration. This is not the right reason to do a pointless (pun intended) test.
The irony is that I have done exactly the same for my own patients in every surgery I have worked in. Perhaps now I need to help more patients dissent, to dissent myself, or better still support those campaigning for a new exception code: “Patient made informed decision to not have test.”
Samir Dawlatly is a GP partner at Jiggins Lane Surgery in Birmingham. He combines clinical practice with being a part time house husband and an interest in social media, as well as publishing poems, essays, and blogs. He can be found on Twitter as @sdawlatly.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am a member of the RCGP online working group on overdiagnosis.