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)

Raising Awareness – Do We Know What We Are Doing?

There was an interesting discussion on Radio 5 Live recently between Glasgow GP Dr Margaret McCartney and Kris Hallenga, the founder of the CoppaFeel breast cancer awareness charity. The interview was arranged in relation to an article Dr McCartney wrote for the BMJ in the first of her new weekly column for the journal, which criticised The Sun newspaper’s rather hypocritical Page 3 campaign to encourage young women to regularly check their breasts for lumps. Whatever you might think of the piece, you have to admire Dr McCartney’s boldness for taking on both a national daily newspaper and the emotive power of the Pink Ribbon for her induction to the column!

The interview exposes how screening for disease and responding to symptoms are so often blurred in the media and by health campaigners – whether this is due to simple ignorance or a deliberate ploy to increase the power of the campaigns is uncertain, but that it is helpful is without doubt. The Sun’s campaign calls for the screening of asymptomatic women through regular breast self-examination, and Dr McCartney’s assertion is that the benefits and harms of this strategy are not sufficiently understood to be able to promote such advice, and what evidence we do have suggests it may do more harm than good. Ms Hallenga, on the other hand says that she ‘ignored her symptoms for so long’; ignoring the symptoms is not the same as failing to remember to check yourself when you don’t have symptoms – there is something more going on here, which brings me to a fundamental problem with ‘awareness raising’ health campaigns.

The logic of raising awareness goes like this: people aren’t seeing their doctor quickly enough about a certain disease – this must be due to a lack of knowledge, understanding and awareness of the condition – there should be a campaign to raise awareness – people will be better informed and see their doctor more quickly – lives and money will be saved. If we were all computer programmes and responded in a predictable way to data input this would work a treat, but people are far more complicated than that.

There are many reasons why someone may choose not to see their doctor when they have significant symptoms. Ignorance may be one of them, but in this day and age of instant health information courtesy of Google, it is surely less of a factor than it used to be – the danger is now the converse, that too much information may be having a detrimental effect. If a woman finds a breast lump – whether by chance or through a belief that she should check herself – she is unlikely to be unaware that breast cancer is a possibility, and yet some will delay seeing their GP despite this knowledge. Other factors must play a part: fear of what might happen next; complex self-denial as we convince ourselves that ‘this can’t be true’; embarrassment; business and the attitude that ‘I haven’t got time to be ill’ are all reasons why someone may not see a doctor – attitudes that might be improved by an awareness-raising health campaign, or might just be hardened by it.

Awareness raising is usually championed by politicians whose motive is to improve a statistic or – for understandable reasons – by those with an emotional connection with the disease in question. The problem with this is that the focus is heavily biased towards those with the disease, with little consideration given to the potential harm to others who may be caught up in the campaign. The justification for this is often that it brings reassurance to those who are checked out and found to be ok – but we should question the merit of a campaign which brings peace of mind to those who have been made anxious by the very same campaign in the first place.

The ‘cough for three weeks could be cancer’ strategy is a good case in point. As with all GPs I have seen more patients with a cough since the adverts appeared – usually non-smokers who are very conscious of their health and would never ignore symptoms for very long – while I am aware of smokers who have been put off seeing their GP by this very campaign because they don’t want to be given bad news. There is rarely any attempt to see how people will respond to these health messages – little consideration given to the fact that the same message might harden the resistance of those who should seek advice while unhelpfully altering the health-seeking behaviour of those who should not. We need to be bolder in challenging this, even if, like Dr McCartney, we end up being accused of acting ‘dangerously’.

Sometimes, though, if you can’t beat them you have to join them, and so I would like to launch my own awareness raising campaign. It’s very simple and it goes like this: ‘Health Awareness Campaigns can do more harm than good – use with caution, apply common sense, and trust your instincts’.

This post was originally posted in Pulse magazine (free subscription required)

Can You Walk off the Risk of Breast Cancer?

One of this week’s health stories is typical of how rather unexciting research can reach the headlines by virtue of its association with a condition like breast cancer, but it also serves as a good example of two of the most common sources of sloppy reporting that plague health stories – which makes me think it a subject worthy of a blog.

The research relates to the possible effect of exercise on the risk of developing breast cancer, and the headline is Walking ‘cuts breast cancer risk’. If true, this is hardly an earth-shattering discovery. Perhaps it will add in some small way to our understanding of the mechanisms involved in the development of cancer, but this is for the journals to worry about. When it appears in mainstream media, the point is surely whether it means anything to an individual concerned about her breast cancer risk – in other words, if you want to reduce your risk of developing breast cancer, should you take up walking? Unfortunately, the way the results are reported makes it very difficult to answer this question.

 

Problem 1: associations are not the same as cause and effect

The first problem is that the study has made an observation, which has been presented as a cause. The researchers did quite a simple thing: they arranged for a group of over 73 000 post-menopausal women to complete a questionnaire at intervals over a 17 year period from 1992 to 2009, asking questions about how many hours walking the women did, and any diagnosis of breast cancer. They found that those who walked for 7 or more hours per week were less likely to have been diagnosed with breast cancer than those who walked for 3 hours or less. This does not mean that the walking caused the reduction in risk, however. It may well have done, but it could have been some other factor. There could have been a different cause that was linked to both breast cancer risk and the amount women walk. For instance, walking less could be linked to obesity, which could explain the extra breast cancer risk.

The researchers were aware of this problem, and tried to exclude some factors – for instance, it was not due to those who developed breast cancer being more overweight than those who did not – but they can never exclude all of the possible confounding influences. For instance, it may be that those who walked less were more likely to have other health problems, and the increased risk of breast cancer was in some way linked to this.

In my experience, observational health studies are very frequently reported as cause and effect. I can understand why – Walking ‘cuts breast cancer risk’ Has more of a ring to it than Walking is associated with a reduced risk of breast cancer. The problem is that the more catchy headline is misleading, and it is left to the reader to spot the error.

Problem 2: what do we mean by a reduction in risk?

The second pitfall when it comes to knowing what to make of a study like this is more serious – and more troubling, because the fault lies not with mainstream journalists trying to enhance their stories, but researchers and journal editors being guilty of the same. The problem is this: as is so often the case, the results have been presented in terms of a reduction in relative rather than absolute risk.

The trial demonstrated a 14% Relative Risk Reduction (RRR) – but is that a 14% reduction of a big number or a small number? If the Dragons in Dragons’ Den are offered a 14% share in company profit, they are very quick to ask how big that profit will be before they part with their money. The same should apply to us before we invest our energies in a health intervention. If the Dragons want to know the absolute amount of money they can expect to receive then we should expect to know the Absolute Risk Reduction (ARR) of any intervention.

The problem is that ARRs are always a lot smaller than RRRs, and so they make research look far less impressive, and researchers are reluctant to give them the attention they deserve. From the BBC article it is impossible to find the ARR, and so you have to go to the original research – and even here only the abstract is available without paying a fee and so you have to work the numbers out for yourself. It turns out that the risk of developing breast cancer over the 17 years of the study was 6.4 percent, making a 14% RRR equate to a 0.9% ARR.

Let us assume for the moment that the reduction in risk really is due to walking. Then if you are a woman after the menopause, and you walk for 7 hours a week rather than 3, then over a 17 year period you would reduce your risk of getting breast cancer by 0.9%. Put another way, if 1000 women walked the extra 4 hours a week for 17 years that would be 3 560 000 hours of walking to save 9 cases of breast cancer, or 393 000 hours of walking per case. At 3 miles per hour, it’s the equivalent of walking more than 47 times round the world! Now I do know that this statistic is probably as meaningless as being given a 14% relative risk reduction – but it was fun to work out!

That’s not to say that walking is a bad idea – there are clearly very good reasons for walking more. However, whatever the associated health benefits might be, the two most compelling reasons to walk will always be these: it’s a very useful way of getting from A to B, and most people find they rather enjoy it!

Who Gave Tesco the Right to Shape Our Children?

I clearly missed the moment when we decided to appoint supermarkets as the powers that should determine our social norms, but it has become clear recently that this mantle has been assumed by at least one of these marketing giants. My attention was drawn to this when the campaigning organisation Let Toys be Toys discovered that Tesco was advertising its chemistry set as ‘for boys’, while its Hotpoint cooker was labelled ‘for girls.’

We need to stop and think about this for a moment – if it does not shock and outrage us in the 21st century, then it certainly should. Surely we have moved on from any suggestion that chemistry is only for boys (were the struggles of Marie Curie and Rosamund Franklin for nothing?) And as for the kitchen…

Can we imagine a school separating children by gender in this way? There would be outrage, surely? Even Michael Gove would think it was old-fashioned!

What is revealing is Tesco’s defence of their actions. When Let Toys be Toys challenged them about the signs on Twitter, they replied with:

So, what they are saying is that they have conducted market research and that is what dictates their policy. The fact that any ethical analysis of the situation can only conclude that toys do not need to be defined by gender apparently has no bearing – the market research (in other words, what sells) trumps any social obligations Tesco might be troubled by.

After some outrage on Twitter (helpfully stimulated by Ben Goldacre) the Tesco account went mysteriously quiet. Subsequently they have apologised for ‘causing upset’ (always apologise for upsetting someone, never for being wrong) and have promised to update the chemistry set as being ‘unisex.’ This they have done, while the kitchen remains distinctly ‘for girls.’ The kitchen is pink – shocking pink – is that enough of a reason to label it for girls, or should we question why on earth a kitchen should be pink in the first place? The answer is clear from the description of another kitchen in the same range:

CookerIt’s not about pink then…

Since then there has been media attention, and Tesco have apparently stated on Watchdog that they will ‘be conducting a review of the way it categorises its toys.’ Why a review and not just an apology and immediate change? Is it that hard? They have decided to change the chemistry set without requiring a review, but I can only assume that working out how to categorise a ‘Wild physic and chemistry set’ is more complicated, since it remains like this on their website:

Physics setWhy does this matter so much? And why talk about it on a health blog? Well, I don’t think we should under-estimate the subversive influences on how we shape our children, or the impact that this will have on their subsequent health as adults. Educational attainment is closely linked to health, and being told you can or can’t do something could have an enormous impact on a child. If parents wish to point their boys towards science, and girls to the kitchen, then that is something I may not agree with (my father is a chef, my wife a scientist, so I’m hardly likely to), but neither should I interfere in another’s parenting without very good reason. Tesco, on the other hand, are not parents and should not presume that they have the right to stereotype in this way.

And when it comes to stereotyping, it is not just how we educate our children that matters to health, but how we feed them. It is nearly a year since Tesco assured me that they would remove the direction to ‘Children’s cereals’ from all their stores, after I pointed out the harmful health message implicit in the signs. Well, as for my local store, I am still waiting…I imagine they are busy conducting a review.

Plain Cigarette Packaging – Does the Government Really Care About Health?

So today is the Queen’s Speech, and the promised legislation on plain packaging for cigarettes has been shelved – put on hold, maybe, hopefully, but probably left to flounder in the long grass until it is somebody else’s problem.

I have no doubt that it takes great courage to take on the might of the tobacco industry – but Australia has paved the way for the rest of the world to follow, it has taken the hit of lengthy legal battles and proved victorious. Our own Government just needs to follow in this lead, and that it has refused to do so does not show a lack of political mettle, but a fundamental problem with political ideology: When it comes to the health of the nation or the health of business, business wins every time.

 

This decision makes a mockery of Government rhetoric on health – promises such as:

These are worthy goals, and it is good to hear the Government talking about them – but they have shown no willingness to play their part in tackling these problems. All of these health outcomes are closely linked to smoking. In response to a recent report on international mortality data, Jeremy Hunt derided the UK health service for ‘shocking underperformance.’

Hunt said the UK was a long way behind its global counterparts and called for action by local health commissioners to tackle the five big killers – cancer, heart disease, stroke, respiratory and liver diseases. He will on Tuesday announce a strategy to tackle cardiovascular disease, which he says could save 30,000 lives a year.

I have blogged my views on this report, and Hunt’s response to it, elsewhere, and so won’t repeat them here. It is not good enough, however, to tell local health commissioners to do better if the Government is not willing to play its part. Many of the biggest health benefits in the history of medicine have come in the area of public health – vaccination, health and safety at work, sanitation and the smoking ban to name a few. Plain packaging could have been the next big public health policy to have an impact. I don’t believe anyone thinks it would be bad for the health of our nation to move to plain packaging; undoubtedly most smokers won’t care what the packet looks like, but it is hardly likely to increase smoking rates.

There are arguments being made against, of course – from the ludicrous notion that small shops will implode because of the extra time it might take shop-keepers to find the right packet, to more reasonable concerns about job losses and counterfeit packets. Suzie Gage has looked at the (lack of) evidence for some of these claims – and as for job losses, well wouldn’t that apply to any strategy to reduce smoking? What should really worry us are the conflicts of interest behind the scenes that may be influencing decisions – like ministers enjoying hospitality from tobacco companies and lobbyists failing to declare their links to the industry.

Instead of doing what it can to prevent disease in the first place, the Government prefers that we wait for it to happen, and then catch it in its earliest stages through screening. This is the thinking behind the NHS Health Check (about which I have blogged here), a hugely expensive programme which may have benefits for a few individual, but where the evidence that it will improve the health of a population is very limited indeed.

And the most frustrating aspect of the whole thing is that the Government’s favoured statistic for measuring our health will actually be best improved by encouraging smoking and then screening for disease. Again, I have already blogged about the unhealthy obsession with 5 year survival data. The truth is that you don’t improve 5 year survival by reducing the number of smokers – because you can’t survive something like lung cancer if you don’t get it in the first place. No, far better to keep people smoking, scare them about cancer enough so that they undertake one of our screening programmes and then cure them – that way we can really make a difference to the statistics and give ourselves a lovely congratulatory slap on the back.

Choices, Choices , Choices

Choice has become a mantra within the public sector, a sine qua non, an indisputably good thing. Politicians are so entranced by its allure that they are blind to both the inherent paradoxes and blatant inequities that are frequently the close companions of choice. The result is that we are often left feeling let down and oddly disempowered.

There are three main types of choice within healthcare: Those that are promised to all but only available to some; those we don’t like to talk about, because the reality is that they aren’t available at all; and those we could all have, but that the powers that be prefer not to tell us about – because they don’t trust us to make the right choice.

The first type of choice we might call the big slice of cake choice. When my teenage son and I cut two slices of cake, inevitably one is larger than the other. With equal predictability, since we are rather partial to cake, we both choose the larger piece – but the reality is that only one of us can have it. Similarly in healthcare – the best surgeon cannot operate on everyone, but who would ever choose the second best? Or I might like to choose the beautiful new hospital on the other side of town, but I have no car and the bus only goes to the tired old DGH down the road.

The result of these big slice of cake choices is that only those with the wherewithal to navigate their way through the confusion of options, and are both savvy and mobile enough to take advantage of the range if choices on offer, will actually benefit – which usually equates to the better off and the less unwell, yet another example of the inverse care law in action.

The second type of choice is the one we like to brush under the carpet – the unpalatable lack of choice that we have to face due to the reality of rationing. The NHS can no longer afford to say ‘yes’ to every health choice we would like to make. The latest, most expensive drug may not be available to us, and our varicose veins may not be deemed worthy of treatment. We are getting used to this in the NHS, and should not be embarrassed by a degree of rationing – although the decisions about what we can and cannot choose need to be made ethically and carefully, and not just by a board of panicked managers frantically trying to balance the books.

The third type of choice is the one that really interests me. It could and should be given to us all, and yet it is rarely talked about – because it has little political value, and involves actually trusting patients. If you are going to trust patients, you have to accept that they can be irrational, unpredictable, and sometimes make foolish choices – and here I speak not as a doctor frustrated by his patents, but as a member of the human race celebrating our glorious diversity.

The choices I am talking about here are these: Should I take a tablet for my mildly raised blood pressure? Should I have a mammogram? How do I feel about statins? These are the sort of health choices many of us are faced with when we visit the doctor, or receive a letter in the post inviting us to engage in a health screening programme. And yet it is rarely presented to us as a choice. We are told to take this tablet, made to feel irresponsible if we ignore the invitation letter, and risk being branded as non-compliant if we disagree – as though it is our duty to bend to the will of the medical profession.

This lack of choice is enshrined in the fabric of the GP contract, as GPs are given an ever-increasing number of targets to aim for – including achieving tight blood pressure control, prescribing anti-coagulants or performing cervical smears. Pressure to deny patient choice comes in the form of prescriptive guidelines, which are frequently dictatorial in the manner in which they tell doctors what they should be done in a particular situation. While evidence-based guidance has been an invaluable tool in helping to achieve excellent standards of care, the words ‘depending on patient individual preference’ appear all too rarely in published guidelines, and doctors are in danger of projecting the pressure that they feel to conform onto their patients.

Many treatment decisions are a complex blend of objective medical evidence concerning risk, and need to take account of highly individual, subjective preferences, priorities and health beliefs. Respecting autonomy is one of the principal pillars of ethical practice, but all too often this is reduced to waiting for the patient to raise objections to the proposed treatment plan, or asking them to become an ‘expert’ in their own health, which can equate to expecting the patient to become the doctor.

True respect for autonomy is a highly active process. It involves creating an environment in which autonomy can flourish, and empowering the patient to make the right choices for their individual situation. It requires that the doctor knows and understands their patient, has a thorough grasp of what matters to them, and is able to distil the available medical evidence into an understandable, personalised format. It may involve supporting the patient when they choose to have treatments or investigations which the doctor would not choose for themselves, or giving licence to opt out of guidelines if they wish to, and turn down treatment without being made to feel like a naughty school child,

This respect cannot be confined to the consulting room, but needs to be enshrined in all aspects of health care – and health promotion in particular. Invitation leaflets for health screening should seek to enable informed choice rather than tell us what to do, and health awareness campaigns should avoid emotional manipulation and never, ever, look like this:

cervical-cancer-poster
Cervical Screening Campaign Poster, Kirklees Feb 2012

On Pacing Spoons and Resolving to do Less

Falling between the claims last week that we would all be subject to Frazzled Friday, and the hazards of negotiating the alleged (and dubiously unscientific) Blue Monday later in January, falls New Year – and the opportunity to make New Year’s resolutions as we face the year to come.

No doubt gym memberships will rise, tobacco sales will suffer a temporary blip, and our eating and drinking levels will return to their pre-Christmas norm. For some of us this will be a powerful opportunity to make significant changes to our lifestyles, while for most I suspect our resolve will be packed away with the Christmas decorations and a promise to try harder next year.

With the busy-ness and stress of our modern lives the bias for New Year resolutions towards trying harder or taking on new things may not be doing us any favours. I wonder if we could change our mindset to resolve to try less hard, and even stop doing something. We could look beyond the usual suspects of cigarettes, alcohol and chocolate and stop doing things which in themselves are not bad – but which conspire with a host of other activities to overwhelm us, leading to stress on family life, a loss of perspective of what really matters, and ultimately ill-health through burnout.

We could resolve to stop worrying so much about making our house into a set for ideal home – by dropping our house-keeping standards just a little or deciding that the bathroom really is ok and maybe we don’t need the hassle of all that DIY this year. We could learn to delegate more effectively at work, and rationalise what we do in the workplace, shedding things that stress us but don’t really matter. We could allow our children to do less – maybe they would really prefer to swim once rather than five times each week, and have been trying to find a way to tell us that they aren’t really hoping to go to Rio in 2016 after all. For the self-employed perhaps we need to find a way to cut our finances so that we really can have that holiday we’ve been promising ourself, but never quite felt able to justify. I’m well aware that I need to be talking to myself here as much as anyone – maybe I need to blog less, Tweet less…oh dear!

I often find myself talking to patients about the importance of pacing. Whether it is recovery from an operation, a debilitating viral infection, depression or living with a chronic illness the principles are the same. Each day you should do something, but still have some energy in reserve by the day’s end. It is sometimes called the rule of 75% – aim to use up about 75% of the pot of energy that you started the day with. That way, if something unexpected happens you still have something left to give – and if it doesn’t then you go to bed with a positive energy balance, so are more likely to wake up the next morning with a bigger starting pot of energy to work with.

A patient of mine has developed an ingenious method for doing this in practice, which she has given permission for me to share here – the idea of pacing spoons. She has to live with a chronic illness which is significantly hampered if she gets her pacing wrong. She has two tubs in her kitchen, containing twelve spoons between them. Each morning the spoons start their day in one tub, and throughout the day she transfers a spoon (or sometimes two) into the other tub whenever she feels she has used up a unit of energy. She makes a deal with herself that there should always be at least one spoon left in the starting tub by the end of the day – and I’m sure that some days she is better at achieving this than others.

The genius of her method is that she has a visual cue for how much she has already done in a day, and so can decide what to take on later in the day and what to defer for another day. Her family can also take a quick look at the spoons when they want to know how things are going. Her children have learnt that a day when the spoons are running low might be a good time to volunteer to cook the dinner, while an evening with plenty of spoons in reserve would be the best time to ask for help with that really tricky homework project. I’m yet to ask her how the family eat dessert when all the spoons are otherwise engaged, but so far this is the only flaw I can find in her system.

If any one else has developed techniques to help with pacing, or you would like to share something that you have resolved to stop doing, it would be great to hear from you.

Wishing everyone a happy, and not too busy 2013!