Ben Goldacre, The Guardian, Saturday 20 March 2010

I don’t write about stories where someone has a conflict of interest, in general, because there are no interesting scientific ideas in them: such stories are a way for people who don’t understand the technicalities of science to give the illusion of critiquing it. But it’s still disappointing to see companies being so much better at getting media coverage for their ideas than everyday folk.

Last month the government proposed a scheme allowing pharmacists to substitute all prescriptions for branded medicines with the generic alternative. Generic drugs are copies of a molecule, but manufactured more cheaply by another company when the inventor’s patent has run out. In almost all cases they are identical, and where they are not, the scheme allows for exemption. A letter of protest appeared in the Times – a spontaneous protest by doctors and patients – signed by various patient groups and experts, with positive coverage in the broadsheets. “Plan to switch to cheaper medicines will harm patients, say experts”, reported the Times. They even had a case study: “Patient given Seroxat substitute felt unwell within two days”.

But Margaret McCartney, a GP in the Britsh Medical Journal, has dug: in fact the letter was coordinated and written by PR company Burson-Marsteller, paid by the drug company Norgine. Peter Martin, chief operating officer of Norgine, despite being the major influence behind the campaign, did not sign the letter himself. Asked why not, he cheerfully replied: “there was no conspiracy. The frank truth, the honest truth, is that I thought that having a pharmaceutical company in there would sully the message somewhat.”

Meanwhile this week you might have noticed the “stay at home” campaign, covered in the Times, Telegraph, Mail, and BBC, encouraging people not to go to their GP with mild self-limiting conditions. This campaign was organised by the Proprietary Association of Great Britain, which represents the manufacturers of over-the-counter medicines and food supplements in the United Kingdom. I think we’re unhealthily obsessed with pills of all varieties, but the PAGB did at least have the courteousy to sign their own letter, and their case is stronger. But their report missed one of the most fun trials ever published in general practise: a randomised controlled trial of the social phenomena of medicalisation.

Doctors commonly prescribe treatments, even when they know they’re not effective, because in the face of assertive patients, demanding a specific treatment, many will chose an easy life. But does a prescription really reduce workload?

Most sore throats are caused by viruses. Doctors usually avoid antibiotics, as a Cochrane review shows only marginal benefits. Explaining the evidence, and prescribing “watch and wait”. Being told that 5 days is the average duration can also help put your misery in a reassuring context. But measuring the benefits of that empowerment requires imagination.

Paul Little and colleagues took 716 patients, who gave written consent to a “study looking at how quickly sore throats settle.” Patients were randomly given either 10 days of antibiotics, or advice to watch and wait, or a delayed prescription, which they could use if things hadn’t settled in a few days.

Patients got better in each group at pretty much the same rate, as we would expect, and got back to work or school at the same pace. More interesting, though, is that many more patients given antibiotics came away with the view that antibiotics were effective (87% vs 55%), and many more intended going back to the doctor if they had another sore throat (79% vs 54%).

So while prescribing antibiotics had marginal benefits on the sore throat at best, it hugely enhanced belief in antibiotics, and intention to go back to the GP. Then, one year later, the researchers returned to the same patients for a follow up study: and they found, looking back, that patients who had been prescribed antibiotics originally were 39% more likely to go back to the GP when they had a sore throat.

The evidence based medicine journal Bandolier (available free online, and highly readable) summed this up by translating the figures from both studies into what would happen in a real surgery, after doctors’ behaviour changed. “If a GP prescribed antibiotics to 100 fewer patients with throat infection in a year, 33 fewer would believe antibiotics were effective, 25 fewer would intend to consult with the problem in the future and 10 fewer would come back within the next year.” Sometimes the most helpful consultations involve no pill at all.