Nagging Never Works

During my time working in hospital I remember seeing a patient in the clinic who came for review after a spell as an in-patient. He had come in with his first episode of chest pain caused by heart disease and he had made a good recovery. What I remember most about him, however, was how emphatically he wanted me to pass on his thanks to the junior doctor who had admitted him:

‘She saved my life, doctor,’ he said. ‘She told me I’d die if I didn’t stop smoking. You know what I did? I handed over my packet of fags and haven’t touched one since; best thing that could’ve happened to me!’

I reassured him that I would certainly pass on his thanks to the doctor, and was glad for his success; what I did not tell him, however, was that my colleague had smoked every one of his cigarettes – ‘shame to waste them,’ she had told me.

What this incident illustrates is the fundamental difference between being in possession of medical knowledge and deciding to act upon it – or in the language of the cycle of change: moving from being pre-contemplative about change to actually contemplating doing something. My medical colleague undoubtedly knew more than most about the risks of smoking, yet she persisted despite the urgent advice she gave to her patient; the presence of crushing chest pain, however, was clearly capable of bringing the same advice into such sharp focus that it motivated radical change.

I often say to my patients that their two best opportunities to stop smoking are to get pregnant or to have a heart attack – a range of options which my male patients find disturbingly limiting. Timely advice from doctors can certainly increase the chance of success, but the studies included in the Cochrane review are of interventions when patients have made an appointment for other reasons. A different question entirely is whether or not we should screen for cardiovascular disease and then provide lifestyle interventions – and the answer to this has appeared in the BMJ recently, and appears to be a resounding ‘no’.

The Inter99 study is a significant piece of work – nearly 60 000 participants with interventions over 5 years and 10 year follow-up, and came to the overwhelming conclusion that screening for risk factors with regular lifestyle counselling had no impact on the incidence of ischaemic heart disease, stroke or mortality. We might be depressed at the poor return for such well-meant efforts, but we should not be surprised: despite the Government’s obsession with ‘making every contact count’, NHS health checks and annual demands in the GP contract to advise our patients again and again about smoking, nagging patients generally does not work.

We know nagging does not work because that is what patients say – receiving health advice when you are not ready for it simply creates resistance and can damage the doctor-patient relationship as this qualitative study in smokers makes clear; it is contrary to all the principles of Motivational Interviewing and against both our training and our experience in the consulting room. The question now is, will policy-makers listen? Will they be bold enough to follow the evidence and stop telling doctors to do things that don’t work, or will they just carry on regardless? Sadly, I think I might know the answer.

This post was first published in Pulse magazine (free subscription required)

Antibiotics for Back Pain – Break-through or False Dawn?

The headlines on back pain this week are hard to ignore. The Guardian, not known for its sensationalist health claims, chose:

Antibiotics could cure 40% of chronic back pain patients.

It’s enough to make a GP sit up and take notice – I can only imagine what I might think if I was living with pain that my doctors had long since given up on.

The newspapers have caught up on an article published in the European Spine Journal in February (funny how these things lie quietly in the medical literature and then all the papers find them at once!) The article was the findings of a Danish trial examining the use of antibiotics in the treatment of long-standing low back pain, and the results are certainly promising – with significant improvement in pain in the treatment group versus placebo. There is a good rationale behind why antibiotics might work, as well as MRI scan findings that should help in the selection of patients who could benefit. The study has been very well critiqued here by Neil O’Connell. I would recommend reading his paper, as I don’t think I can better his analysis.

The key question is what the medical establishment now does with the findings – we need to tread very carefully. At the moment this is the result of a single research group in a relatively small study. For all we know this may have been caused by a statistical blip, an unseen bias, or even scientific fraud (I have absolutely no reason to think it is fraud, but we should never be so naive as to not consider this as possible, until findings have been replicated elsewhere). The results certainly justify a large, multi-centre trial to fully evaluate the hypothesis.

The problem is that we already have the technology to evaluate back pain with an MRI scan, and the antibiotics are established and inexpensive drugs. The temptation for doctors to agree to treat their patients with antibiotics ‘to see if it works’ will be very great – especially for patients in whom nothing else is working. We must resist this, as there are two equal and opposite dangers if we do not.

The first is that this turns out to be an erroneous finding, and thousands of patients are unnecessarily investigated, treated and harmed before, years down the line, the hypothesis is finally refuted and practice reverts to normal. The history of medicine is littered with examples of this – from the horrors of frontal lobotomies in the 50’s, to unnecessary tonsillectomies in the 70’s, or the over-use of aspirin in primary prevention of heart disease and stroke as recently as the last decade. It can be quite a task to put the Pandora’s box of over-treatment back where it came from once it has been unleashed.

The second danger is that this really is a break-through. That it is the Helicobacter pylori moment in the treatment of back pain (Helicobacter is the bacterium responsible for the majority of stomach ulcers and its discovery and treatment has revolutionised the management of this condition). If this is so, then we need robust evidence to establish this new way of thinking so that the majority of people can benefit. If treatment starts to become commonplace without evidence then it could remain the territory of private clinics and maverick surgeons who are more focused on pleasing their patients than practicing robustly evidenced medicine. NICE may never approve it, or take several more years to do so than it should, and many patients may miss out in the long run.

So what to do if you have back pain? Well, for now it is best to watch this space with interest. We really do not know at this stage if you would benefit from antibiotics or not. If a clinical trial starts, seriously consider enrolling on it – so that you can play your part in answering what is clearly a pressing clinical question.