By Margaret McCartney. London: Pinter and Martin, 2013. ISBN 978-1-78066-000-4. Paperback, 335 pages. $22.
As a young doctor, keen on the latest knowledge, I joyfully chirp to anyone within earshot, “there’s no good evidence for this!” while deprescribing a patient’s inappropriate medication. A pill, continued for years out of inertia, habit, or lack of reconsideration, has risks and side effects that outweigh whatever benefit the drug may have once been intended to provide. I am a less-is-more kind of doctor, keen to make sure patients have what they need, but not enthusiastic to pepper them with hyped-up tests or treatments until we know the facts and the patient and I agree that they can offer more good than harm.
This is a tough balance to strike, as patients and doctors are under constant pressure to undertake aspects of care that may be inappropriate. I gather courage in the form of The Patient Paradox: Why sexed-up medicine is bad for your health, by Dr Margaret McCartney, a GP from Glasgow and regular contributor to the British Medical Journal.
This book resonates, changes practice, stirs existential angst, confirms deep suspicions, and will drive us all to be better doctors and more engaged patients. But if you want to remain shielded from criticism, do not read it.
It explains the harms of turning people into patients—or worse, consumers—and the paradoxical problem of “not getting medical care when you are sick and need it.” This is the inverse care law, originally described by Julian Tudor Hart, a Welsh GP, who wrote in 1971, “the availability of good medical care tends to vary inversely with the need for it within the population served.”
The example-packed narrative of The Patient Paradox acknowledges the gaps with evidence and encourages skepticism and commonsense thinking to interpret the little evidence that is available. Our lack of reverence for the basic principles of statistics, the factors that make up a good screening test, and the hierarchy of quality of evidence, as well as a misplaced trust in measurements of surrogate markers and proxy outcomes can lead us astray.
Of course, good intentions lead to bad results as we navigate—as patient or provider—our discomfort with uncertainty and a bias that more is better. “Doctors tend to be vocational people who want to do good things: if you found out that your [intended] ‘good thing’ was to cause the deaths of thousands of babies or cancer in millions of smokers you might react, at least initially, with a measured disbelief. We all have vested interests.”
McCartney confronts this head-on. She tackles misconceptions and cognitive biases, dissects marketing mumbo-jumbo (like the nomenclature of the “war on cancer”), exposes indication creep (like the fact that the prostate-specific antigen or PSA was never designed as a screening test), and calls out both subtle and overt conflict of interest in medicine.
The sexiness of relative risk reduction, consumer choice, and new drugs and technologies, along with the embarrassing reality that many doctors still take money from the pharmaceutical industry, are tough to combat. The cult of awareness driven by charities advocating for awareness of their choice of disease presents great challenge as this kind of awareness “does not mean education, designed to impart knowledge and understanding. It is awareness designed to attract attention, alarm, and publicity, which often ripples panic and bad statistics in its wake.”
Citing the unintended harms of cancer screening and cardiovascular risk assessment, The Patient Paradox reminds us that “one has to accept the possibility that what seems logical and useful may even have harmful effects” and acknowledges that “this is a horribly hard lesson.”
McCartney begins to make the reader worry that nothing can be trusted, but she presents a clear path for doctors: we must care for our patients.
We must remember the person in front of us and be aware of the context in which they live. The only question the book fails to answer is why the obvious and low-cost magic bullets of exercise, healthy diet, avoidance of poverty, and consideration of other social determinants of health are not undertaken more readily.
There are many models of patient interactions, “but all make it clear that you will fail unless you find out why the patient is there.” McCartney emphasizes that the relationship between patient and provider is at the core of good medicine. We must develop trust and provide patients an opportunity for truly informed consent, but more importantly we must form a connection. Evidence supports that continuity of care results in better outcomes and lower costs. In particular, the book highlights a study that showed “if the doctor was interested in the patient, positive, and clear in communication, patients were more satisfied with the consultation as well as more enabled to deal with their illness. If doctors failed in the consultation, patients were likely to suffer symptoms for longer and have unnecessary referrals made to hospital.”
It then follows that medical professionalism must re-emerge from its long slumber. “It is only with ‘making the care of the patient the first concern’ that the current patient paradox can be ended, that ill can be properly cared for, and the well escape futile tests and treatment.”
As health care providers we must hold ourselves to a higher standard, and this book implores us to do so. McCartney invites us to “demand evidence and think critically.” Start by reading the book, reconsidering the way you view health care, and gathering the courage to joyfully care for people the way you’ve always known was right.
—Jessica Otte, MD, CCFP
1. Hart JT. The inverse care law. Lancet 1971;297(7696):405-412.
2. Little P, Everitt H, Williamson I, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ 2001;323:908-911.
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