Science Based Wellness

Or: Quis custodiet ipsos custodes? (Who shall guard the guardians themselves)

In my previous post I analysed the results of the JUPITER drug trials. I demonstrated that, for the participants, the benefits of taking Rosuvastatin (Crestor) were slight while the risks were far from negligible.

I shall now explain how this translates into a difference of opinion with Healthy Skepticism. However, first, a general comment.

Most Australian doctors are dedicated to doing the best for their patients. I have never encountered a doctor in Australia who prescribes medication in a cavalier fashion. What follows is not an attack on doctors generally or on any one doctor.

It is however an attack on what might be called the “Medical Establishment.” I believe the leaders of the medical profession have let their members down badly.

Let us return to the JUPITER trials. Suppose you read TIME magazine’s puff piece on the benefits of statins generally and Crestor in particular. Not realising that TIME employs scientifically illiterate journalists to write about medical matters you truly believe that the JUPITER trials were one of the 10 top medical breakthroughs of 2008.

What do you do?

You go and have your CRP levels checked to see whether there is any sign of inflammation. If it turns out that your CRP levels are elevated you start dosing yourself with 20mg of Crestor per day for the rest of your life.

You need a prescription to buy statins

Except that if you live in Australia, the UK, the US or most industrially advanced countries you can do nothing of the sort. You cannot walk into a pharmacy and buy Crestor or any other statin over the counter. First you need a prescription from a doctor. A pharmacist who sold you a statin without a valid prescription would be breaking the law.

Why do you need a doctor’s prescription to buy certain drugs?

Why is that? Why is there all this bureaucratic “red tape” about buying a heart medication? It’s not as if you can get high on Crestor. DUI means driving under the influence of alcohol, not Crestor. There is no record of Crestor crazed motorists wreaking havoc on our roads.

Crestor is safer than alcohol. A 20mg dose of Crestor probably does you less harm than the average cheeseburger with fries. Given the mysterious growth in nut allergies you are probably safer giving a stranger a Crestor pill than a peanut.

Alcohol, cheeseburgers with or without fries and peanuts are all freely available. So for that matter are cigarettes. Why restrict the sale of Crestor and not cigarettes? You may get ill from second-hand cigarette smoke but people can pop Crestor pills in your presence without harming you one iota.

Governments restrict the sale of Crestor and other medications because they believe, or purport to believe, that a medically untrained person cannot take such decisions on their own. We need a skilled professional to tell us what medication to take. That is why we grant doctors a monopoly of the prescription pad.

Doctors value their monopoly of the prescription pad

Make no mistake, doctors value this monopoly as is demonstrated by the Australian Medical Association’s strong objections to allowing “nurse practitioners” to prescribe.

I agree with the Australian Medical Association

Now I happen to agree with the Australian Medical Association. I think highly trained professionals should keep a monopoly of the prescription pad. I do not think that nurses have the scientific training that will enable them to keep up with the ever accelerating advances in biology. And I shudder to think what would happen if we ever allowed pharmaceutical companies to sell their products directly to the public.

We need doctors to guard us against misleading pharmaceutical advertising

Fact is, we need trained doctors to guard us against being misled by pharmaceutical company advertising.

What does the Healthy Skepticism website say?

Now consider the following quotes from the Healthy Skepticism website:

“Companies would not spend such massive amounts on promotion if it were not effective at influencing prescribing. …”

“Promotion influences prescribing much more than most health professionals realise…”

“Many advertisements and statements from pharmaceutical representatives are misleading…”

“Reliance on promotional information may endanger lives and expose prescribers to the risk of litigation…”

“Thirteen observational studies have found that exposure to pharmaceutical promotion and doctors positive attitudes towards pharmaceutical promotion both correlate with harmful use of pharmaceuticals….”

This is tantamount to whining:

“Oh poor little us. Those nasty people in the pharmaceutical companies keep bombarding us with misleading promotions and we keep believing them.”

Does this sound as if the leaders of the medical profession are behaving like worthy custodians of the prescription pad?

Here is a quote from the Healthy Skepticism website concerning the JUPITER trials.

“So there you have it. A possibly unethical trial with marginal results gets trumpeted in the media as showing “wide benefit” (New York Times). Based on the laudatory quotes coming from the leaders of the American College of Cardiology, this off-label use of statins will quickly find its way into clinical practice guidelines and drug compendia. Within a few years, health care payers will be forking over billions more dollars to the statin drug makers in the name of preventing heart disease.” (Emphases added)

This “off-label use of statins”will only “find its way into clinical practice guidelines” if the leaders of the medical establishment allow that to happen. The pharmaceutical companies may attempt to persuade but they cannot compel the profession to adopt clinical practice guidelines.

The nub of my philosophical difference - who is to blame?

And here is the nub of my philosophical difference with Healthy Skepticism. The blame for inappropriate prescribing does not lie with the pharmaceutical industry or “the system.” Nor does it lie with most doctors.

The blame lies squarely with the leaders of the medical profession’s professional bodies. They have shamelessly abdicated their responsibility to ensure that their members have access to high quality, unbiased continuing professional education; professional education that is free from the taint of pharmaceutical company promotions.

I said that we need doctors to guard us from “Big Pharma’s” misleading advertising. More than 2,000 years ago the Roman poet, Juvenal asked:

Quis custodiet ipsos custodes? (Who shall guard the guardians themselves?)

In the case of the medical profession this can only be the leaders of the doctors’ professional bodies. If they fail to “guard the guardians” the vacuum will be filled by pharmaceutical companies and snake oil salesmen.

Not an attack on doctors generally

I want to repeat that this is not an attack on doctors generally. Most doctors really do have the best interests of their patients at heart.

Healthy Skepticism still part of the solution

Flawed as I believe it to be, Healthy Skepticism is part of the solution, not part of the problem.

Tags: ama, australian medical association, crestor, ethics, healthy skepticism, jupiter, mansfield, prescribing

This entry was posted on Sunday, June 14th, 2009 at 9:18 pm and is filed under medical ethics. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.