Fifty years of change

Fifty Years of Medicine 1969-2019

A personal take on the most important developments That have shaped how medicine is or Should be practised

Five decades of clinical medicine F​​ifty years. That’s how much time has gone by since I entered medical college.

‘If it’s Parkinson’s disease prescribe carbidopa-levodopa​’

A lot has changed since then. Science and technology has developed in astonishing and unimaginable ways. So too has the practice of medicine. Not just the ​‘what​​’ of modern diagnostic and therapeutic tools available to us but, in my view far more importantly, the ​‘how’​​ of medicine. It is the ‘how’ that I write about in this essay.

Rules are good; in some situations they help more than hinder. But In much of modern medicine the treatments we prescribe are aimed more at preventing or delaying bad outcomes, than ‘curing an illness. Here, clinical epidemiology has replaced rule-based medicine with ​data-driven medicine​​. Now we know that in the absence of known ischaemic heart disease giving a statin for 5 years does no good for the vast majority2 of patients who take them. The rule and the data are in conflict.

How we approach our profession, how we use and choose to deploy the technologies available, and how we deal with patients and populations.

Here is my list of the most important developments in the last half-century, and how they have (or should have) influenced our professional lives.

1​​ ​The rise of clinical epidemiology1as a basic tool for clinical practice.

Back in the early 70s, we learned clinical rules.

Rules that were handed down from teachers we revered.

‘If a patient had fever and a productive cough for 4 weeks suspect TB.’ ‘If it’s TB treat with 3 drugs for 18 months.​’ Today some of still follow rules: ‘If the cholesterol is high, prescribe a statin for life’

​Clinical Epidemiology: A Basic Science for Clinical Medicine. Aug 1991. Sackett DS, Haynes RB, Tugwell P and Guyatt G. Lippincott Williams and Wilkins, Hamilton, Ontario 1

We know now that clinical diagnosis is not a binary decision. In most situations it is a fuzzy business that involves making a probability statement. Nor is it a one off event but rather it is an iterative process involving ​prior and posterior probabilities​, ​positive​ and ​negative predictive values​, and ​sensitivity​ and ​specificity ​of test results.

Equally, in most situations treatment interventions (whether drugs or procedures) are no longer a 1:1 mapping of a pill for every ill. Now, thanks to clinical epidemiology, it is a complex choice dictated by the natural history of the disease, the expected benefit from the treatment, the patient’s expectations of the outcomes that are important to her/him, an understanding of risks of the proposed treatment, and the likelihood of net benefit. The idea o net benefit3 itself involves an understanding of side-effects and drug interactions Clinical epidemiology has shown us that a drug like a statin that reduces the risk of death by 50% (​wow! That must be a great drug!!)​ actually means that you will have to treat a large number of 2 3

​https://www.ncbi.nlm.nih.gov/pubmed/29267889

https://www.theguardian.com/society/2018/aug/30/modernmedicine-major-threat-public-health

patients for many many years for 1 of them to actually derive net benefit. This number is the famous NNT or Number Needed to Treat. We had never heard of the term when we studied medicine in the 1970s Clinical epidemiology is also the science that cautions us from falling too readily into the trap of believing that making an early diagnosis is a good thing. It may be, in a small number of cases, but for many people, it is not. The terms Overdiagnosis4 and Overtreatment5 arise from a realisation that excessive zeal in the practice of high tech medicine causes real harms.

2 The advent and maturing of evidence-based medicine (EBM) Back in the day, we learned from clinical teachers and professors who gave us the rules of clinical practice. Now teachers give us not rules but principles of how to learn​​, how to keep up to date, and how to evaluate evidence.

Not enough doctors imbibe these principles but it is a growing movement, that is less than 3 decades old. The basic idea is that preceptor-based learning is limited by the experience and knowledge of the preceptor. Evidence-based medicine draws on the benefits of a vast body of recorded and analysed experience to inform the choices we make.

That sounds like Nirvana. But the reality is that it isn’t quite as rosy a picture as first imagined. Big Pharma6 has found clever and disingenuous ways of subverting it for it’s own ends.

But essentially, EBM is one of those things like morality, honesty and integrity, that depends on our willingness to apply the principles as best we 4

https://www.bmj.com/specialties/digital-theme-issue-overdia gnosis 5 ​https://www.bmj.com/too-much-medicine 6

https://www.waterstones.com/book/bad-pharma/ben-goldacr e/9780007498086​ and also https://badscience.net/files/The-Doctor-Will-Sue-You-Now.p df

can, while being aware that charlatans abound even within our own ranks.

3 The Information revolution and the democratisation of medicine If computing power drove clinical epidemiology, the world-wide web drove evidence based medicine. And now with the widespread availability of computers on our desks, in our homes, and in our hands, the information revolution has led to a new development that has changed clinical practice. Information is no longer a trade secret.

Until late in the last century medical knowledge was like knowledge of the Vedas millennia ago. A few high priests had the knowledge - and the power. The rest had to make do with what they were told.

Knowledge of all sorts has now been democratised. The intelligent layman can read up the clinical pharmacology of, say Tamsulosin, and tell you, the doctor who prescribed it, that you should not have done so. He was already taking Prazosin and both are Alpha-adrenoceptor blockers. The fall he suffered as a consequence of postural hypotension was your fault, he might say.

If we link together the democratisation of clinical information and the fact that vast areas of clinical practice are to do with discretionary choices in an attempt to reduce the risk of adverse outcomes over the medium - long term, then an interesting idea emerges. That the old rules based clinical practice should give way to to a new model.

A new model in which the patient is no longer the passive recipient of the doctor’s wisdom and knowledge, but an active participant in shared decision-making. The role of the thoughtful physician then is not so much to prescribe an intervention but to guide, and explain the evidence and the data, evaluate the risks and potential benefits and costs and help the patient make the choice that is right for him or her.

If this sounds fanciful and unworkable then it’s worth remembering that less than a century ago so did cardiac catheterisation, until Werner Forssmann did it on himself in 1929.

4 Medicine as politics7 But perhaps the biggest change in the last 50 years has been the increasing recognition by the medical profession that medicine is not an end in itself; that it is but a means to an end. That objective goes beyond the patient in front of the individual doctor.

The ultimate objective has to be the health, welfare and well-being of the community we serve, the population of people from which our patients come. It is an end that we can talk about as individuals, but if we are to do something to achieve it , we need to come together and work as a profession.

If ‘​health is the highest law​​’ then the profession of medicine has a powerful voice to speak up and be the advocate on behalf of our patients, both present and future patients.

We need to lobby and campaign for better health policies; for Governments to respond, not just by building hospitals and paying doctors to treat the sick, but also to ensure that the fundamental determinants of health are in place. And what are these?

preparedness against natural disasters; and yes, it also includes ▶a health care system that provides an agreed level of care for the commonest illnesses. ‘​Medicine is politics by other means’,​ it has been said. Too often we underestimate the importance of Government agencies in maintaining and promoting the health of the people. Every time we immunise a child, or prescribe a drug, or recommend a course of radiotherapy we depend on a vast array of regulatory processes that ensure that the vaccine or the drug or the radiotherapy kit meets certain standards of purity or quality.

As a profession, medicine needs to ally with the other caring professions and campaign for a fairer, less unequal, non-violent society that respects diversity and values the contributions of all sections, genders, and groups in society, and that places the needs of the most vulnerable groups at the top of the pile for resources and attention.

Medicine is no longer one man or woman doing clever and heroic things in splendid isolation. It was always a team effort. The ‘team’ just got bigger, more diverse, and more distant.

The determinants of health8 include, among other things, ▶A just and equal society; ▶safe, clean adequate water and sanitation; ▶sufficient food and food security; ▶a satisfying and safe employment for all who want it; ▶decent habitation; ▶a quality education system that provides for all; ▶freedom from violence and from the threat of violence; ▶safe, affordable public transport; ▶defences and 7

http://www.who.int/primary-health/conference-phc/decla ration 8 http://www.who.int/hia/evidence/doh/en/

JN Rao Class of 1969