Ben Goldacre, Saturday 31 October 2009, The Guardian.
Every now and then it’s fun to dip into the world of politics and find out what our lords and masters are saying about science. First we find Brooks Newmark, Conservative MP for Braintree, introducing a bill to reduce the age for cervical cancer screening to 20. The Sun has been running a campaign to lower the screening age, on the back of Jade Goody’s death at 28 from cervical cancer, and gathered 108,000 signatures on a petition. The Metro newspaper have commissioned a poll showing that 82% of 16 to 24-year olds in England agree with lowering the screening age.
“Cervical cancer may be rare in women under 25,” says Mr Newmark: “but it is inexcusable to dismiss the cases that occur as negligible statistics.” Oh, statistics. “We have a vaccination programme that ends at the age of 18 and a screening programme that begins at the age of 25. That leaves young women between the ages of 18 and 25 caught in a medical limbo, eligible for neither vaccination nor screening.”
Somebody should do something: an intuition which you will find at the bottom of many calls to extend screening programmes beyond the population in which they can provide useful information, and into low risk populations where they simply waste resources, or do more harm than good.
If screening worked, you would expect to see a reduced incidence of cervical cancer diagnoses in people who have been screened, compared with people who have not been screened, in the 5 years after screening: because precancerous lesions will have been detected and dealt with before they got to a more advanced stage.
In August 2009 the British Medical Journal published a large study examining this very question. It found that screening was associated with an 80% reduction at age 64, 60% at age 40, and so on. But cervical screening in women aged 20-24 has little or no impact on rates of invasive cervical cancer in the following 5 years. Only the Liberal Democrat MP Evan Harris introduced these findings to the debate (with the rather excellent line: “The honourable Member for Braintree cited evidence from The Sun, so I want to refer to a recent edition of the British Medical Journal”).
Meanwhile on the very same day David Tredinnick, Conservative MP for Bosworth, stood up to speak on medicine. Scientists and doctors who doubt the efficacy of alternative therapies are superstitious, ignorant, and racially prejudiced, he explained. “It is no good people saying that just because we cannot prove something, it does not work… I believe that the Department needs to be very open to the idea of energy transfers and the people who work in that sphere.”
He went on. “In 2001 I raised in the House the influence of the moon, on the basis of the evidence then that at certain phases of the moon there are more accidents. Surgeons will not operate because blood clotting is not effective and the police have to put more people on the street.”
Where does this moon stuff come from? “I am talking about a long-standing discipline—an art and a science—that has been with us since ancient Egyptian, Roman, Babylonian and Assyrian times. It is part of the Chinese, Muslim and Hindu cultures… Criticism is deeply offensive to those cultures,” says Tredinnnick: “and I have a Muslim college in my constituency.”
Any attempts to challenge Tredinnick’s ideas are based, he explains, on “superstition, ignorance and prejudice” by scientists who are “deeply prejudiced, and racially prejudiced too, which is troubling.” So I hardly dare to mention that Tredinnick tried and failed to claim £125 in parliamentary expenses for attending an intimate relationships course teaching how to “honour the female and also the male essence and the importance of celebrating each”, run by a homeopath.
Meanwhile the flag-bearers for conservatism at the Spectator are now promoting climate change denialism, as George Monbiot has pointed out, and Aids denialism, under the tedious flag of “only starting a debate”, even in their print edition. And finally, the NextLeft blog recently pointed out that of all the top ten conservative blogs, every single one is sceptical about man-made climate change. It could be an interesting five years ahead.
skyesteve said,
November 3, 2009 at 1:10 pm
@emen – some more thoughts on screening for gynaecological malignancy – there are about 600 new cases of ovarian cancer each year in Scotland (rare under 30 years of age with peak incidence in 60s); the average Scottish GP would see one new case every 5 years so high index of suspicion needed. There is a scoring system (that I don’t claim to fully understand) which is supposed to help with decision making with possible ovarian cancer. It’s called the RMI score and uses a combination of ultrasound findings, Ca125 level and menopausal status to identify “high risk”.
Targetted screening is suggested in some quarters for women with 2 first degree relatives with ovarian cancer OR 1 with ovarian and 1 with breast cancer under 50 years of age OR 1 with ovarian and 2 with breast under 60 yoa OR 2 with colon + 1 with some other gut malignancy at least one of which miust be under 50yoa. These recommendations come from the 2003 SIGN guideline on ovarian cancer –
www.sign.ac.uk/guidelines/fulltext/75/index.html
With cervical screening 5 yearly smears reduces the incidence by 83.6%, 3 yearly by 91.2% and annually by 93.3%. As I say decision to do 3 yearly based on these figures, pros and cons of false +ves and false -ves and cost to the NHS where rationing is an every day fact of life in one form or another.
olster said,
November 3, 2009 at 1:54 pm
Apologies if this is already somewhere in this thread but…
As if by magic, Physician’s First Watch (for November 3, 2009) covers the news that US physicians OVERUSE (my emphasis) the PAP.
“Only about one fifth of U.S. clinicians consistently follow guidelines for Pap testing, with many overusing such screening, according to a federally funded survey in Annals of Internal Medicine.”
That’s Annals of Internal Medicine, November 3, 2009 vol. 151 no. 9 602-611
Annals link here: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd291SDX5%2FSGYmQgAvUUEcvOXc%3D
American Cancer Society guidelines on cervical cancer screening: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd299mxUmz6Ccp8gAvUUEcvOXc%3D
American College of Obstetricians and Gynecologists guidelines: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd297NNK1oN0PxZgAvUUEcvOXc%3D
and:
USPSTF guidelines: click.jwatch.org/cts/click?q=227%3B67304842%3BytM6Q3zlk%2Fy9s5bkO%2Bd29%2FxSiuB8%2Fit6gAvUUEcvOXc%3D
So when people claim the US screen more people, they may not in fact be doing so under their own guidelines.
olster said,
November 3, 2009 at 2:00 pm
@njdowrick & @squander two
>@squander two (#43): you say
>“There is a slight difference between bodies moving in
>a vaccum, being affected only rarely by anything other
>than their own momentum and each other’s gravity, and
>climate, many of the significant influences on which
>are still understood either incompletely or not at all.”
Something being affected by its own momentum????
I thought this went out of the window with Newtonian physics!
A body moving through a vacuum will not be ‘affected by its own momentum’, but will only be affected by new forces applied to it (gravity etc). Momentum IS NOT A FORCE!
(disclaimer- I am not a physicist, but I do have an intercalated radiological physics degreee… Almost the real thing!)
emen said,
November 3, 2009 at 4:57 pm
skyesteve, thank you!
it was very interesting
In some EU countries (including France and Germany) women are advised to have a yearly “overall” gynaecological screening, with a smear test and and ultrasound test and all that, even if they haven’t got symptoms. But of course, the financial arrangements are different, a higher percentage of the GDP is spent on healthcare, rationing is not that strict etc.
mikewhit said,
November 3, 2009 at 6:34 pm
Thanks for the update on screening.
I think it just needs more awareness by the GP, and willingness to refer for tests, since in the case I am familiar with, no TV ultrasound was performed initially, it was just put down to a digestive issue.
As I may have said on here before, I believe there is an unwillingness in the UK to refer a GP patient for tests, the assumption is that whatever it is will just sort itself out, which is probably largely true.
However I personally know of three other cases where a test would have caught an eventually fatal condition, when the person had been to the doc before with symptoms but sent away with ‘let’s just wait and see’.
One, stroke/cerebral, the other two, cancer not counting the ovarian cancer first mentioned.
skyesteve said,
November 3, 2009 at 6:55 pm
@mikewhit – it’s back to that thing about medicine being a mixture of science and art. “Watchful waiting” as it’s commonly referred to is a long-established part of good primary care – and long may it continue otherwise we have the over-the-top, fear-of-litigation led healthcare seen in other parts of the western world which, to be blunt, is just crap medicine.
I would hope a good GP would always say to someone with new but non-specific, non-“red flag” symptoms “if these symptoms persist for more than a week or two you need to come back and see me as we may need to look into this problem further”. If we simply perform (or refer for) a whole battery of tests on any patient presenting with new non-specific symptoms the whole NHS would grind to a halt rapidly.
Please don’t forget that, although it may not seem like it to you, we have the best, most evidence-based primary care in the world (at least in Scotland we do!) IMHO.
natsils24 said,
November 3, 2009 at 7:51 pm
@ mikewhit
Sadly medicine is not an exact science and sometimes wait and see can actually be a good strategy, I have seen it use very effectively by hospital consultants and GP as sometimes pathology is not clear cut at first. We call it watchful waiting and it should be just that, we wait to see what happens but with regular appointments in order to detect any change in clinical status. I think the whole debate surrounding screening, which as I said I fully support is the fact that it is just that, it is screening. No screening test is 100% accurate, both false positives and false negatives, and tests are fallable. Thats why they have to be used with caution and why patients should be fully informed of the symptoms of the disease that is being screened for so they can present if they are concerned.
@ skyesteve
The RMI score is used to decide where the patient should be managed in a cancer unit or at a specialist cancer centre due to their risk of malignancy.
emen said,
November 3, 2009 at 7:51 pm
mikewhit, I agree with you:
“there is an unwillingness in the UK to refer a GP patient for tests, the assumption is that whatever it is will just sort itself out”
with the addition that I wouldn’t want to see a doctor if I wanted to wait for it to sort itself out, would I.
If the GP refers somebody for a scan and the result is normal, I wouldn’t call it “wasting resources” but a more accurate diagnosis. More accurate than one which is based on mere guessing.
The question is: what can you do (in order to save your life)? I think there is a rule on this blog that we shouldn’t discuss personal medical history or conditions here, so all I would say that the lesson I learnt is that sometimes you simply have to go private.
Squander Two said,
November 3, 2009 at 8:05 pm
olster,
> Something being affected by its own momentum????
Yes, I obviously know this. However, we were talking about computer modelling. In a model, the movement of an object is affected by the code simulating its momentum. The fact that that code doesn’t represent a real-world force makes it a different type of effect, not a non-effect.
I’m a pedant myself, but I at least try to be pedantic in context.
natsils24 said,
November 3, 2009 at 8:16 pm
@ emen
I think sometimes GPs get a bit of a hard time. They have an exceedingly difficult job, every day they have to distinguish between patients with symptoms that could be caused by something innocent, or something extremely sinister. It is like the needle in the haystack at times. In hospital we have the luxury of tests, and scans but sometimes we forget to use our clinical judgement. We are taught to look for horses, not zebras, i.e. if the symptoms fit it probably is something common, but always keep the rare things in mind. Scans and other tests help but 80% of diagnoses can be made on the basis of history alone, with examination findings helping to support it. And scans are never perfect.
This doesn’t apply to screening which is a centralised process that GPs actively encourage people to go for.
skyesteve said,
November 3, 2009 at 8:21 pm
@emen – of course there will be people who individually are not happy with the service they receive from the NHS and I sympathise with them. If something doesn’t go well for you that’s clearly bad for you as an individual. But no system is perfect (there aren’t enough robots to go round as someone once said).
The fact remains that, for primary care at least, we have levels of satisfaction (and I am only qualified to talk about Scotland) that are the envy of any other service or industry at levels nearing 99%.
I don’t know any GP that relies on “mere guessing” as you put it. We do try an practice evidence-based medicine and the new contract encourages that. Good medicine is, as I say, about good history taking and examination which will help define the tests that will help to confirm the diagnosis and guide the treatment.
But the majority of people presenting to GPs do have mild self-limiting problems or chronic non-life-threatening problems the management of which is not helped by a whole load of unnecessary tests.
The problem with doing lots of tests on lots of people is that you run the real risk of unnecessary anxiety or inappropriate reassurance.
You say that a normal scan isn’t wasting resources. But if we refer people for tests that they don’t need that does cost money which has to be found from finite resources. It also means that someone else who does need the test might have to wait longer for it and thus have their diagnosis and treatment unnecessarily delayed.
It’s a difficult circle to square but by and large I think we get it right most of the time.
olster said,
November 4, 2009 at 5:18 am
@Squander Two
re: > Something being affected by its own momentum????
Ah- yes, sorry about that- you are obviously a victim of me being a latecomer to the party… I really should read the other posts next time!
outeast said,
November 4, 2009 at 11:36 am
Is it just me who saw Tredinnick’s comment on having a Muslim college in his constituency as a dog-whistle to his fellow Members? I heard it as, like, ‘OK chaps, you know why I’m saying this, we all know it’s balls but I get to please my constituents by saying it and you get to ignore me, so everyone’s happy and no harm done.’ But then, I’m a big one for the principle of charity…
lizD said,
November 4, 2009 at 3:32 pm
To add to the EU/US/UK information on screening, in Australia, the screening age is 17, regardless of whether you are sexually active, with tests done every two years. If you have an abnormal result, you are screened every six months after treatment until you have a clear test again.
As someone whose sister was diagnosed with ‘abnormal’ cells at 23, treated and given a clear bill of health, I’d have to agree with lowering the screening age and getting more information out there in a form that doesn’t cause public hysteria.
natsils24 said,
November 4, 2009 at 9:48 pm
@ lizD
Firstly I don’t see the point in ever doing a smear test on someone that young who has never been sexually active. The vast majority of cases of cervical cancer are due to HPV infection which is sexually transmitted, plus I would not like to be the person doing a speculum examination on someone who has not been sexually active.
There will always be cases of someone who has had abnormal cells at a young age, however, the evidence for screening this young age group is just not there at the moment and this is why we don’t screen them, unless they have worrying signs or symptoms. And in the UK we practice evidence based medicine, we have to use the avaliable research to guide policy. Which is the case with the current UK cervical screening programme.
Chi Square said,
November 5, 2009 at 5:16 pm
Hi Ben,
This is unrelated to this week’s column, but I was just watching and interview with Suzanne Somers about her new book “Knock Out”, a book about treatment options for cancer patients; a subject on which Ms. Somers claims to be an authority on as she has “survived” cancer (by “survive” she means she was misdiagnosed). A lot of outrageous claims were made in this 3 minute interview and I would appreciate it if you would look into this and perhaps write a column on it in the near future. By the way, I just finished your book and in Canada we don’t refer to Aboriginal peoples as “native Canadian Indians”.
longyan said,
November 6, 2009 at 2:25 am
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csrster said,
November 6, 2009 at 11:12 am
Chi Square: Ben’s already clued up on Suzanne Somers. See
the link “Can you let me know the moment this person lands in the UK please” in the miniblog.
Dirg said,
November 6, 2009 at 7:07 pm
Thank goodness in Canada any female can ask for and receive a pap test. Here it is recommended that a female get a pap test every year starting in your late teens (or as soon as you become sexually active). Two of my girlfriends had pre-cancerous cells when they were teenagers, another girlfriend had outright cancer in her teens and another friend had cancer in her twenties. Without a regular pap test all of these women would have died, and apparently had they lived in Britain they would all be dead.
adamk said,
November 6, 2009 at 8:05 pm
@emen and mikewhit
when a GP says ‘come back if its not better in 2 weeks’ you can think of that as a test – a ‘if its not better in 2 weeks we may need to investigate further’ test. This is a very useful and valid tool.
I think people often have an almost magical belief in ‘tests’ , a belief that there is an investigation out there which will tell them exactly what the problem is. This is often not the case.
Also tests and scans are not without there inherent dangers – every CT thorax/abdomen performed exposes the patient to a large dose of (possibly cancer inducing) radiation , for example.
Then there is the money question – it seems to be taken as bad taste to mention health care and money in the same breath , but is the reality of the NHS. For every unnecessary test , money is spent that might have been better spent elsewhere.
On the subject of screening , mammography , the other great screening programme in the UK for women , may be an example of the dangers of too much screening. there is some debate as to whether mammography is picking up large numbers of very early breast cancers, which would have never developed into anything serious. The women involved then have to go through traumatic surgery , and emotional turmoil , which may have been completely unnecessary.
skyesteve said,
November 6, 2009 at 10:17 pm
@ dirg – there is no evidence that annual screening, especially in young women under 20, significantly reduces the mortality from cervical cancer. An abnormal smear does NOT mean cervical cancer – it doesn’t even mean you will go onto develop cervical cancer. There are three grades of abnormal smear before you get anywhere near cancer – CIN 1, CIN 2 and CIN 3 (CIN = cervical intra-epitheleal neoplasia). We know that if left alone one third of CIN 1 will revert to normal, one third will stay at CIN 1 and one third will progress to CIN 2; for CIN 2 one third will regress to CIN 1, one third will stay at CIN 2 and one third will progress to CIN 3; even at CIN 3 one third will regress, one third will stay static and one third will progress to cervical cancer.
What happens in Scotland is you get you first smear at 20 then every 3 years after that. If at any stage you are found to have CIN you will almost certainly be referred to a gynaecologist for colposcopy – direct visualisation of the cervix using a microscope at which point the extent of any lesion can be identified, biopsies taken if necessary and treatment initiated (which may include excision of the transition or transformation zone – effectively the junction between the external and internal surfaces of the cervix – this is the usual area at which malignancy arises; alternatively a large biopsy – so-called cone biopsy – may be taken to assess the extent of any abnormality if this is not obvious at colposcopy). Subsequent follow-up depends to some extent on the severity of the initial abnormality but for lower grades at least it would typically consist of another smear after 6 months and, if that was okay, another after 12 months and, if that was okay, back to routine 3 yearly screening thereafter. You might find the following link useful.
www.screeningservices.org.uk/csw/prof/quality/colp_sopps09/c150_follow_up.pdf
Your statement that “all of these women would have died” is simply not evidence-based and cannot be substantiated. It is the kind of “shock, horror” headline of the tabloid press which is just not helpful. Sorry.
quasilobachevski said,
November 8, 2009 at 2:08 am
Dirg,
I don’t have much to add to skyesteve’s very informative reply, but as a Brit living in the US I want to comment on one sentence.
The clear implication here, commonly repeated on the likes of Fox News, is that there are treatments which are simply not available in the UK (because the NHS is a crypto-Stalinist government-run organization etc etc).
This is not the case. Certain treatments are not covered by the NHS, and if you want one of these you have to “go private” and pay for yourself, just as you would in many other countries. You can take out health insurance, if you choose to.
I realise that this wasn’t exactly what you were getting at, but I’m so fed up with the coverage of these issues here that I feel the need to combat this insinuation whenever I encounter it.
emen said,
November 8, 2009 at 4:55 pm
skyesteve #56
I agree with you, of course, on the principle of watchful waiting. Let me tell you an (imaginary) example to clarify what I mean.
A female patient turns up at the GP, with severe abdominal and low back pain. The GP listens to her story, takes her temperature, examines her abdomen, exludes appenticitis and some other things. At that point he is left with 1. PID 2. vaginal infection 3. severe cystitis 4. ectopic pregnancy (and I can’t know what else). He knows that he needs to have some tests and scans done to decide what is wrong.
What happens then? Is he going to ask her to come back next Tuesday, when the practice nurse is there?, and she will take some swabs and samples, then he will wait for an extra week for the results to come back. Meanwhile, he prescribes the patient two different types of antibiotics, in the hope that one of them should work on whatever it is that she has.
Or should the GP ask her to go to A&E?
Or is there any way for that patient to see a urogynaecologist within 2 days, who can do the scans and tests? Without being admitted to hospital?
I’m not criticising the GP service here, at all: I am really trying to understand how the service works.
Because I wouldn’t think it would be safe for this patient to wait for two weeks and see, or would you?
What I’m sometimes concerned about is problems like these: that are not long-term managable conditions, like asthma, and not life-threateningly dangerous to go to A&E, but the GP surgery is not equipped enough to do the necessary tests and scans. What happens then?
That is (also) what I meant by the GPs being reluctant to refer patients for tests and scans.
emen said,
November 8, 2009 at 5:09 pm
quasilobachevski #72
“Certain treatments are not covered by the NHS, and if you want one of these you have to “go private” and pay for yourself, just as you would in many other countries. You can take out health insurance, if you choose to.”
That’s exactly what I often think.
But the NHS should also be honest and not feel embarrassed to “mention health care and money in the same breath, when it is the reality of the NHS.”
Cervical smear testing only once in 3 years, and only if you are over 25, because we can’t afford to waste resources on investigating false positive results. A small number of cancer cases will be missed, but only a small number. You can have it done as often as you want, privately.
But really, they should stop mumbling things like “we have evidence-based medicine here” = everybody else in the world is a bunch of idiots if they screen more often and we are cleverer than anybody else.
skyesteve said,
November 8, 2009 at 8:52 pm
Hi Emen. Thanks for you reply – I can only speak for myself but in the scenario you describe let me work my way through your own differential diagnosis if I may:-
1. appendicitis – yes I know that you exclude that but the key here may be the history and examination(sorry to keep harking back to that) – fever, nausea/vomiting, tachycardia (sorry, fast heart rate), perhaps some looseness of stool; pain that starts initially in central abdomen and is “colicky” in nature (i.e. gripping quality that comes and goes) but then becomes more severe, constant and shifts to the right lower abdomen (right liliac fossa – RIF) would be strongly suggestive of appendicitis; examination may reveal tenderness in the RIF associated with guarding (where the muscles tense up in repsonse to peritoneal irritation) and rebound (an extra spasm of pain when the hand is removed from the abdomen suddenly). This person has appendicitis till proved otherwise (although if their period was also late then you would have to consdier ectopic) and I would admit her as an emergency.
2. PID – again fever would possibly be present and there may be some abdominal tenderness and guarding/rebound; pelvic examination might reveal tenderness to either side of the cervix in the upper vaginal vault together with discomfort when the cervix itself is moved (so-called cervical excitation); if her period was late then again an ectopic would need to be considered in which case I would do a pregnancy test there and then (modern pregnancy tests are very sensitive); I would also check her urine for white cells, red cells, protein and nitrites (which are produced in the presence of bacteria); I would also do chlamydia and high vaginal swabs and take blood for a full blood count (to look for high white cells which would suggest infection) and an ESR (erythrocyte sedimentation rate which increases in presence of infection or inflammation) – I can also do the ESR in my consulting room with result in an hour.
Thereafter how I proceed would depend on how well or otherwise the patient was (and you have to take into consideration my 20 years of experience here) – if she was not too unwell and PID seemed likely I would commence antibiotics (whilst awaiting test results) and probably review her in 24 to 48 hrs depending on my level of concern; if she was unwell I would have no hesitation in admitting her as an emergency to Gynaecology.
3. vaginal infection – these tend to be superficial (although vaginal abscesses can occur) and there would possibly be vaginal discharge (in which case I would take swabs and possibly commence treatment based on likely diagnosis). Straightforward vaginal infections tend not to make someone unwell per se. If they were unwell I would proceed as per PID above.
4. ectopic pregnancy – you are right to mention this; it must always be considered in women of fertile age who are sexually active and, as said, may present like PID or appendicitis, although there is often some vaginal bleeding too together with a history of late period and positive home pregnancy test ( or symptoms of early pregnancy). If I had even the smallest suspicion of ectopic pregnancy this lady would be admitted as an emergency to gynaecology.
5. Don’t forget the possibility of sexually transmitted infection, though again with this I would proceed as per PID.
In the end of the day it comes down to how unwell the person is (and possible diagnoses) as to whether I admit them or arrange to review them. It’s not unusual if I am concerned sufficiently about someone (but I’m not sure whether they need admitting) for me to review and reassess someone that same day.
You right, most GP surgeries don’t have in-house ultrasound scanning (though some do). This is because to be good at anything like that you need to do it regularly. Most GPs would not be able to keep up their skills and this would then risk things being missed. There are sound reasons why specialist services are centralised as they are.
Hope this is helpful and, perhaps, reassuring. Please remember most GPs (and, indeed, most doctors in general)have the interests and needs of their patients at the forefront of their decision making process.
In the UK we get a fantastic deal – nobody pays “up front” and GPs don’t have to worry about the costs when making clinical decisions.
Contrast this with the USA where I did some primary care research. Here’s one anecdote that I saw (and couldn’t believe) with my own eyes – lady has a definite pathology requiring a specific drug which her doctor wants to prescribe but before he can he has to phone her insurance company there and then in the consultation to ask (a) can he prescribe this drug type for the lady (remember clinically there is NO doubt she needs it) and (2) if so which brand should he prescribe (he tells me the insurance company keeps changing brands every few weeks in attempt to cut costs by ensuring the cheapest brand is used). Now remember this lady is one of the lucky 40% of US citizens who actually has insurance coverage. Can anyone really say that’s a better system than the NHS?
P.S. Who are the coolest people in hospitals? The ultra-sound people…
quasilobachevski said,
November 9, 2009 at 12:59 am
skyesteve,
Thanks for another very interesting and informative post. But I can’t let this go unmentioned – the real stats are shocking enough without this sort of exaggeration. I believe census information indicates that about 45 million Americans don’t have health insurance. The population is roughly 300 million, so about 15% of people are uninsured at any one time.
Many people drift in and out of insured statues (depending on their employment status etc) so the number of people uninsured at some point during any one year is somewhat larger, but nowhere near 60%.
quasilobachevski said,
November 9, 2009 at 1:05 am
“Many people drift in and out of insured statues”
Ooops. Of course I meant “status”! Ben, any chance of a preview button for comments?
skyesteve said,
November 9, 2009 at 7:59 am
Sorry quasilobachevski – you’re quite right and I should have been more precise. When I was working in the USA (in New Mexico) the figures I saw suggested that 40% had FULL insurance cover. So I accept I should have put in the word FULL and also that my figures may be time and locality specific and therefore not generalisable (is that a word?!).
skyesteve said,
November 9, 2009 at 9:15 am
Oh, and figures suggest 71% of working adults in the US have difficulty paying medical bills (including 41% with insurance – in otherwords they are under-insured i.e. they don’t have FULL coverage).
www.ncbi.nlm.nih.gov/pmc/articles/PMC516134/
In the UK this is just not an issue.
quasilobachevski said,
November 9, 2009 at 5:28 pm
skyesteve,
This seems very plausible – indeed, I’m not quite sure what “full” insurance would mean. Most health insurance in the US requires “copayment”, so the patient pays a proportion of the cost of each procedure.
There’s no doubt in my mind that the NHS is a massively better system than the US model, both in terms of cost and coverage. (Indeed, I don’t really understand how the Glenn Becks of this world can persist in asserting the contrary.) I merely wanted to correct that one factual point.
skyesteve said,
November 9, 2009 at 7:31 pm
quasilobachevski – you are quite right – mea culpa – I should be more specific/accurate with the statistics I use here (that’s part of the purpose of this site afterall!).
However, the concept of “under-insurance” is a well-recognised part of the US healthcare debate with up to 75 million Americans aged 19 – 64 are either under-insured or have no insurance at all:-
brighamandwomens.staywellsolutionsonline.com/RelatedItems/6,616350
The precise figures don’t really matter. I think we can both agree that the issue is that the wealthiest nation on Earth denies a substantial minority of its citizens the right to modern high-quality health care and its politicians would rather slag off the NHS (which, for all its faults, is a fab service) rather than get their own house in order. I think it’s called free market economics or something like that…
quasilobachevski said,
November 9, 2009 at 8:46 pm
skyesteve,
Exactly!
emen said,
November 12, 2009 at 12:25 pm
Wow, thank you, skyesteve!
OK, let’s see.
“I would do a pregnancy test there and then (…), I would also check her urine for white cells, red cells, protein and nitrites (…), I would also do chlamydia and high vaginal swabs and take blood for a full blood count (to look for high white cells which would suggest infection) and an ESR (erythrocyte sedimentation rate which increases in presence of infection or inflammation) – I can also do the ESR in my consulting room with result in an hour”
So you could (would if necessary) do a
1. pregnancy test
2. urine test
3. blood test
4. vaginal swabs
5. ESR
there and then, in your surgery, within the 10-minute appointment, with the results available immediately or on the same day?
Because if yes, I will have to move to Scotland (from England), because I have never heard of anything like that happen in a GP surgery here. My GP can’t do any of these tests, the nurse (with whom you would have to make another appointment) can do the urine and can take the vag. swabs, but she needs to send them off somewhere to get analysed (takes about a week). No bloods taken by the nurse, you have to go somewhere else, make an appointment first etc.
Wow again.
Also, I agree with adamk that
“When a GP says ‘come back if its not better in 2 weeks’ you can think of that as a test – a ‘if its not better in 2 weeks we may need to investigate further’ test. This is a very useful and valid tool.”
but in practice, this often means going back again and again, the GP trying out different tablets or increasing doses without doing any test or referring you anywhere, in fact treating something he doesn’t know what it is for weeks or months.
emen said,
November 12, 2009 at 1:09 pm
“Can anyone really say that’s a better system than the NHS?”
No.
But you will find that there are other countries in the developed world apart from the US and the UK.
Why is it that everybody who critices the NHS is always immediately told about healthcare in the US?
Why don’t you look at the French, German or Finnish system?
In France (in general), you pay for one third of your healthcare costs. Normally you take out insurance or you can pay as you go. If you can’t afford insurance, the state will pay for the missing third.
In Germany, you pay 11-13% of your income to a healthcare company, the state pays for the rest. If you are not employed, you get the service free.
Both systems are a bit more complicated than that, but the basics are true: everybody gets the service and if you earn enough, you pay for a part of it. For that contribution you get a MUCH BETTER service than the NHS. Yes, it is possible to do a hernia operation one week after the diagnosis, and not have to go on a nine-month waiting list.
Yes, a doctor CAN sit in the room while you are having your MRI scan and dictate the findings into a dictaphone as the images are being made, so afterwards the secretary types it up, gives it to you and you go away KNOWING the results (compare in the NHS, where even if you have a suspected cancerous tumour, and you have been in the specialist system for months, the doctor can allow himself – clinical guidelines will allow him – two weeks before looking at the images, and then comes the multidisciplinary team meeting, where they will all decide that they have no idea, and give themselves another week to think about what to do to find out.)
Somebody said on this blog a few months ago, that you now have access to psychotherapy on the NHS within 2 months or sooner. I decided to investigate: I asked a friend of mine who is a psychiatrist, and the answer was: oh, no, of course not, not in the area where she works. The waiting list is 2-3 years, or it WAS, before they were told they can’t refer anybody for psychotherapy for the time being. They need to sort out this waiting list first, nobody can even GET ON IT.
Swine flu vaccine? Free, sure. But only if you are in the risk group. If you are not in the risk group, you will not get it. In other EU countries you might contribute TOWARDS the cost if you are not in the risk group, but at least you can decide whether you want it or not.
I don’t think I am far from the truth when I say that people who have lived in another Western European country and have ever experienced better, will NOT say that the NHS is a fantastic system. It is free (at the point of receiving the service!), but you pay a huge price for it being free: you simply don’t get the quality of the healthcare that should be possible in the 21st century.
(The NHS generally has quite a bad reputation in Western Europe, if you are interested.)
And what choices have you got in Britain? You can go private, take out insurance or pay from your savings when you need it. In private healthcare, the service is completely market-oriented, where your membership fee goes up as you get older, if you have had a complicated disease etc., it might not cover what you need. Just like in the US.
And where did we start? Oh, cervical cancer screening. Ben criticising the MP who introduces a bill to lower the screening age. And people from other countries commented how younger women are included in other countries and benefit from it.
It seems to me that it is a taboo to criticise and suggest reforming the healthcare system in Britain. Like you are immediately a bad person or something.
But we will never have a better healthcare system here if we keep repeating that it is better to provide bad quality healthcare than no healthcare at all, and that the only alternative would be the US model.
skyesteve said,
November 12, 2009 at 9:48 pm
Emen – 1. pregnancy test – yes I can do this in the consultation with result available in about a minute or so.
2. urine test – again I can do a basic “dipstick” test – this will help to identify the presence of white cells (suggestive of infection), nitrites (suggestive of infection), protein (suggestive of infection but also found with kidney disease), blood/red cells (suggestive of infection but can also be caused by bleeding anywhere along the urinary tract), ketones (found with fasting or in poorly controlled diabetes) and glucose (found in diabetes of course). All these things can be tested for by a single dipstick with all results in maximum of 2 minutes. Sadly dipsticks are not conclusive and, although I may make a clinical decision on them (e.g. start antibioticsfor possible urinary tract) this decision would be made in conjunction with the history and physical examination and I would usually send the sample to the lab for full analysis – microscopy (to look for significant levels of white and red blood cells), culture for infection and, if significant dipstick protein, urine protein levels.
3. blood tests – these do have to be sent away but basic results (e.g. full blood count, kidney function liver function, etc.) are usually available online in about 2 working days. I can access them directly from the lab’s results system from my consulting room computer if necessary and in a case of real urgency I can ask the lab to do the tests when they receive them so they may be available the same day if I time the pick up lab van right! In the near future we are hoping to have a machine in our adjoining community hospital that can do these basic blood tests which of course will speed things up considerably.
4. vaginal swabs – again these go to the lab and do take a few days for results for the simple reason it takes that long to culture up bacteria. Some GPs will look at “wet smear” in their consulting room to look for trachoma which can be seen under a microscope but I don’t do that myself.
5. ESR – yes I do this in my room with result in an hour.
Oh, and in my practice, 15 minute appointments are standard which definitely helps. But there’s nothing above that couldn’t be done in any average GP surgery – I’m certainly no super-doc.
emen said,
November 13, 2009 at 10:41 pm
An interesting point in today’s New Statesman by Mike Richards
Mike Richards: “Undoubtedly, our cancer survival rates have been poorer than many other countries. The question is, why? The more we look into that, the more apparent it is that late diagnosis is the problem and, therefore, failure to get the patient to the curative treatment. The curative treatments for cancer are very often not that expensive. The best treatment for cancer in many cases is surgery, and well-done surgery is not that expensive, whether it is for breast cancer, lung cancer or colorectal cancer. We are simply not picking up patients early enough.
This comes back to the previous discussion about primary care, of which I am a very strong supporter; I am from a family of general practitioners. We have tied the hands of our general practitioners to a certain extent because we have asked them to be overzealous gatekeepers, but we have not given them access to diagnostic tests. This is why I so strongly welcome the recent announcements that we will improve access to diagnostics for GPs. For cancer patients, for example, this will mean that people who have a low risk of having cancer based on their symptoms – but not no risk – will be investigated, and investigated quickly. The vast majority will then be reassured, but the small number who are found to have cancer will go into the system at a curable stage. That is a very important point. We need to put more emphasis on diagnosis and take more money out of the hospital system in terms of people being in beds when they do not need to be.”
emen said,
November 13, 2009 at 10:43 pm
…who is the national cancer director at the Department of Health
www.newstatesman.com/health/2009/11/health-care-system-change-nhs
skyesteve said,
November 15, 2009 at 12:45 pm
For England? It’s Prof. Mike Richards
www.dh.gov.uk/en/AboutUs/MinistersAndDepartmentLeaders/NationalClinicalDirectors/NationalDirectorsBiography/DH_4105307
skyesteve said,
November 15, 2009 at 9:37 pm
…but not for Scotland, Wales or Northern Ireland. I don’t know about Wales or Northern Ireland but here in Scotland we have our own initiatives on cancer.
Anyway, I haven’t read the article but it’s hard to disagree with that part which you quote Emen.
But this doesn’t say “let’s screen everyone for every thing every year”. Nor does it mention the very real morbidity associated with unnecessary investigation. It’s a very difficulat balance to strike but I think on the whole, at least in my part of the world, we do the best we can.
I have no problem getting someone seen within a week or two for necessary assessment if I have the slightest suspicion of cancer but at the same time I have a prime directive – ” do no harm” – and that means not causing unnecessary physical and psychological morbidity by over-zealous investigation.
That’s where “art” plus over 20 years experience comes in (I hope!).
Right, no more posts on this one – I promise!
bodenca said,
November 16, 2009 at 4:08 pm
I think if I were an early twenty-something women, I would still be dissatisfied with the justification of NHS policy within this thread, although all its main elements have appeared.
So, I’ll be melodramatic and see if that gets the general arguments across. Here goes!
There is no such thing as a “screening programme”. Screening does not give true positives and false positives. It just gives positives. These have to be found true or false by a follow-up test. It is a “screening and follow up programme” or useless.
In assessing risks of a potential programme, the follow-up is critical. It is usually (more) invasive. It may involve ionising radiation. Will this small intervention danger to a larger number of false positive patients cause more suffering than would the greater disease danger to the smaller number of true positives if left undiagnosed?
In assessing resource usage also, the resource-demanding follow-up is usually critical. How much suffering will the diversion of medical skills, facilities and equipment away from other treatments cause? Added to the suffering of false positives if the programme goes ahead, will this exceed the suffering of true positives left unscreened until they present later? This is the case whether health treatment is a cost to a national service such as the NHS or to a health insurance fund, or some fancy mixture of the two.
Perhaps the Scottish NHS policy was a “best guess” but more recent consideration could show the English programme to be wiser. The Scots are likely to carry on regardless because it is so difficult to withdraw an unwise service once it is established.
Then again, as both screening and follow-up procedures are improved, the time to extend screening in England to a further age cohort may already have arrived, but not yet be statistically demonstrable.
We know only that it is unsound to ground criticism of one nation on the past judgements of another, not which is better.
That said, distrust any overseas system which relies even in part on private insurance companies (or medics) who may vie to show they are “better” by offering medically unjustifiable screenings and treatments. And now our papers, and some politicians, are trying to do the same.
heavens said,
November 20, 2009 at 11:07 am
@23 says, “I am glad to live in another European country which recommends getting a PAP test as soon as you become sexually active.”
Um, that’d be pretty much worthless.
The point of a pap smear is to find cervical cancer caused by a sexually transmitted virus. It takes years for this virus to cause cancer, not days or weeks — “years”, as in “median latency is generally believed to be 15 to 30 years”. Pretty much nobody has ever seen any sort of clinically detectable change in less than one year, which makes “as soon as you become sexually active” kind of silly.
Have you perhaps confused a pap smear with a pelvic exam? (That is very widely recommended “as soon as you become sexually active,” or even before then.)
Or do you think that your country’s health service thinks all the women lie to their physicians about their sexual lives? I suppose that if the regulator thought that most women were having sex at age 15, but lying to their docs until they were married at age 25, then you might suggest “as soon as you are willing to admit that you’re sexually active, because we believe that’s several years after you really started”.
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ignoranceisalearnedbehavior said,
November 22, 2009 at 1:01 am
Living in the US currently where things are often done differently (and sometimes not at all) it occurred to me that this might be of interest,
www.acog.org/from_home/publications/press_releases/nr11-20-09.cfm
particularly this excerpt, “A significant increase in premature births has recently been documented among women who have been treated with excisional procedures for dysplasia. “Adolescents have most of their childbearing years ahead of them, so it’s important to avoid unnecessary procedures that negatively affect the cervix,” says Dr. Waxman. “Screening for cervical cancer in adolescents only serves to increase their anxiety and has led to overuse of follow-up procedures for something that usually resolves on its own.” Naturally I haven’t read the original report or looked at the research data, but it’s noteworthy that the [insert unfavored press body of the minute] lobby is asking for something even the treatment-hungry Americans are finding of dubious benefit at best, harmful at worst.