7971:1 – What will you trust when it comes to the safety of HRT?

You get used to outrageous medical claims in the press, but The Telegraph has truly surpassed itself today with its front page headline declaring that ‘HRT ‘is safe’ for postmenopausal women after all‘.

The article states that new research ‘has found no evidence that HRT is linked to any life-threatening condition’, and makes much of the fact that the new study followed women for a decade. There is a quote from Dr Lila Nachtigall, one of the study authors and a Professor of Obstetrics and Gynaecology at New York University who claims that: ‘the risks of HRT have definitely been overstated. The benefits outweigh the risk.’

Prof John Studd from London is even more forthright, saying: ‘Most GPs are afraid of HRT – they will have learnt as medical students that it is linked to health risks. But those studies that were replicated in the textbooks were worthless. They collected the data all wrong.’

These are bold statements, and so you would expect them to be based on a significant piece of research. The main study that Prof Studd so comprehensively dismisses is the British Million Women study – over 1 million women were studied specifically to look at the risk of breast cancer with HRT and it found a small, but significant, increased risk. To overturn the findings of such a significant piece of research would require something big.

So what is this new research? Well the article, as is so often the case, fails to tell you – but if you are still reading as far as the 11th paragraph you may start to have your doubts: the study followed 80 women. 80! Not 800 000, or even 80 000, but 80! To be fair, when you look at the study itself it’s actually 136 – 80 women on HRT and 56 without. So with 1 084 110 women in the million women study and 136 in this new, apparently game-changing research – that’s 7971:1.

What’s more, when you look at the new study in detail (and here I’m grateful to Adam Jacobs on twitter who managed to locate it) the study was not designed to look at the safety of HRT – the intention of the research was to answer a question about the effects of HRT on body fat composition, and any findings on the safety of HRT were only a secondary consideration. What is more, it is described as a retrospective cohort study – that means it looked backwards at the history of these 80 women, so if a woman had got breast cancer related to HRT she might not have been alive to take part in the study in the first place.

Even if the study had been designed to prove there was no link between breast cancer and HRT, the Million Women study suggests an increase of only 5 extra breast cancers in 1000 women taking HRT for 10 years – so 80 women would only have 0.4 extra breast cancers between them – meaning the study is far too weak to draw any conclusions at all. Oh – and the study was sponsored by Pfizer, who might just have a commercial interest in lots more women going on HRT.

The Telegraph was not the only newspaper to pick up the story, but it was by far the worst reporting among the broadsheets – The Guardian, for instance, picked up the small number of women in the study and tried to bring a sense of balance to its piece – just so long as you read past the headline and the first two paragraphs.

In closing, I would like to say one or two things to Prof John Studd of Wimpole Street. The first is that if you are going to have an official website it would be best, for reasons of probity, if you could include an easy to find declaration of interests; maybe I am being dense, but I failed to find yours. Secondly, GPs are not afraid to prescribe HRT – and we have learnt one or two things since medical school – but we do like to prescribe it after having a discussion with the woman concerned about the balance of benefits versus risk, as we like to base this on reliable evidence.

And for a woman considering HRT wondering what all this means? HRT remains the best way to control symptoms of the menopause, which can be very distressing. There is an increased risk of some cancers, but it really is quite small and many woman feel it is well worth taking that risk in order to feel well; have a chat with your GP about it.


Call Me Old-Fashioned

Last week I wrote an article for The Guardian concerning the new Channel 4 programme Health Freaks. My concern related to the fact that three GPs could be at the centre of a TV programme that used what I consider to be the very derogatory term ‘freaks’ in its title. For me, the word has been chosen because of its eye-catching quality, and the implied promise of entertainment based on voyeurism. I was intrigued by the comments the article generated, however, as they were generally unsympathetic to my views.

On the whole those who made a comment thought I was a bit over-the-top in writing the piece, and I admit that it was certainly strongly worded. There were two types of argument supporting this. The first was that I was misjudging the use of the word ‘freak’ and that it was not intended in a negative fashion, and the second that I was far too easily offended, guilty of over-cooked political correctness and generally needed to find a sense of humour.

The first arguments were well put, and I can certainly see that one use of the term ‘health freak’ is to describe someone who is particularly health-conscious, along the lines of being a fitness fanatic. Had the programme been about that sort of person then I would certainly agree with this point, but given the fact that the first programme focussed on someone who thought it benefitted his health to drink his own urine, I think the producers had something rather different in mind when they chose the word.

For the second argument I think the readers missed the point of what I was trying to say (and here I must look back at my writing and conclude that I could have said it better). The issue I have is not that this is the most offensive programme on television, nor that the word ‘freak’ is the worst term we shall hear over our airwaves – not by a distance. My problem with the programme is that the presenters are doctors, behaving in their capacity as doctors, and so the professional relationship that stands between doctors and patients still applies to the programme, even if it is now between the presenters and the members of the public on the show.

Call me old-fashioned, but I make no apology for expecting doctors to demonstrate the highest standards of professionalism at all times, and that respect for our patients is at the core of this. It is the damage done to this professional value that offends me about the name of this programme – since calling someone a freak in a voyeuristic sense of the word is hardly respectful. You could call it a plea for politeness and good manners – or are these words too boring to be permitted these days?

I do know that doctors are human beings, with human frailties. When it comes to always respecting our patients amongst the day-to-day stresses of a pressured day we will all fall short at times, me included, and our professional values are something to be aspired to, but will not always be achieved. I also know that our personal lives will be as messy as the lives of our patients, and that this should not usually have any bearing on our ability to do our job. However, making a TV programme is not the product of the heat of the moment or the end of the day when your compassion is at a low ebb. It is a fully considered judgement in the cold light of day, and so there is every opportunity to have the highest ethical standards when doctors make TV programmes.

A parallel setting to making a TV programme is when doctors engage in clinical research. Here too doctors consider proposals for working with patients, there is every opportunity to think things through in an ethical and considered way for the protection of patients, and every opportunity to get it wrong if the right values are not properly applied. For this reason every research proposal has to be considered by an ethics committee to assess its suitability – in terms of patient safety and respect for patients – before the public is exposed to our ideas. Doctors in the media have chosen to act in a public way, they should at least expect close public scrutiny of their actions.

I am not proposing that this programme should be banned (the principle of freedom of expression is far too important for that!) or even saying that I find it that offensive, but neither will I concede that it is naive to expect the highest standards from my profession, nor will I ignore the tendency for entertainment to trump values at every turn – at least not without a fight!

Hypochondria – a Word Desperately in Need of a Makeover

Hypochondria is an ancient word. It stems from the Greek meaning for the upper abdomen; hypo- is the prefix for below, and -chondro refers to the ribs, so that the Greeks referred imaginatively to the upper abdomen as ‘the bit below the ribs.’ For the Greeks, the abdomen was felt to be the seat of melancholy, in the same way that we consider the heart to be the home of love. At some point in the history of medicine, this psychological association with the word hypochondria developed pre-eminence over its anatomical origins, and the condition of hypochondriasis was born.

Since that time, however, hypochondria has taken a bashing. The problem starts with the fact that it makes such very good comedy. Whether it is an icon portrayal by a master of the art such as Tony Hancock, or throwaway one-liners like ‘Hypochondria is the only illness I don’t have‘, the image of someone endlessly worried about their health is irresistible material for laughs. This I can handle – comedy is part of how we cope with the human condition, and we should never be so sensitive about illness that we are afraid to laugh at it.

More of an issue, however, is when the condition is misunderstood – and unforgivably so, when this is done willfully. A particularly bad example of this was written in The Observer recently by the columnist Barbara Ellen. It may be that she is simply ignorant of the nature of hypochondriasis, in which case she is guilty of gross journalistic laziness, and should improve her research. However, with a sub-title that reads: ‘Hypochondriacs are themselves a pain – and they take up valuable surgery time,’ I suspect that she knew full well what she was doing and was happy to take cheap potshots in order to sell a story.

The text of the article is even worse than the headline. Ellen was apparently trying to be on the side of doctors, empathising with why we might sometimes be tempted to prescribe a placebo. An article that alleges to understand my frustrations as a doctor has rarely left me so angry, but with outrageous claims like: ‘the fact remains that there is no known cure for the determined hypochondriac attention-junkie’ and ‘hypochondriacs are shameless liars’ the only way I was able to keep my blood pressure in check while I re-read her rant, was to remind myself that she is a professional journalist who has set out to shock and I shouldn’t take it too seriously.

There is a serious side to this, however, which is that words affect attitudes, and attitudes drive behaviour. True hypochondria is a fearful and much stigmatised illness; the way we talk about it will influence the way doctors, patients and the public in general behave towards those affected, and at the very least I feel the need to try to redress the balance a little.

At this stage I should say what I mean by hypochondria; it is easier to start with what it is not. It is not someone who worries a bit more than most about their health. Neither does it describe those among us who are – and there is no other way to say this – a bit of a wimp when it comes to suffering. Some of us do complain more than others, and our friends, families, and even our doctors, have to put up with this – but that is not hypochondria. Nor is it malingerers who make things up for personal gain – people who pretend to be ill in order to skive off work for a bit. Despite what the Government would like us to believe, I don’t think there are many people like that, but I would be naive to say that they do not exist – although they are not hypochondriacs. Most importantly, hypochondria does not refer to illness that cannot be explained by doctors – medically unexplained symptoms are common, and their causes many and varied, while hypochondria is rare and quite specific.

A true hypochondriac really is worried that they are unwell. The illness is often focused on one fixed belief – a lump in the throat becomes a cancer, abdominal cramps can only be explained by a bowel infestation. The level of anxiety takes on an obsessional, even delusional, quality, with a constant drive to find an answer for the symptoms, and a need for reassurance that can become like an addiction. Just as an alcoholic finds his thirst is slated only for a while with a drink, so reassurance brings an all too temporary reduction in anxiety, and as soon as it wears off anxiety rises to overwhelming levels, with a search for more reassurance being the only offer of respite.

A patient may check their body for changes 30, 60 or 100 times a day; it can dominate conversation with friends and family, exasperating all involved. The internet – always a mixed bag when it comes to health information – becomes a snare, with its 24-hour availability and tendency to promise answers, while usually delivering just more questions. Reassurance-seeking behaviour, inevitably, involves frequent trips to the doctor, A&E, specialist clinics, investigations – the risk from medical tests and treatments becomes a very real danger. This is a debilitating and life-controlling illness – hardly the domain of a lying, time-wasting whinger.

The challenge with hypochondria is to help someone move from focusing on physical symptoms to an understanding of the nature of their anxiety. This is hard enough without having the very word for their illness mired in stigma, ridicule and misunderstanding. I suspect Hypochondria as a diagnostic label is now beyond rehabilitation – which is why the illness is often referred to today as health anxiety – but the word still exists in our popular vocabulary, and we should treat it with respect, because it will continue to represent the experience of real people with real lives.