The healthcare system is facing failure, rooted in an epidemic of misinformed doctors and patients.
During a recent keynote lecture at the British Association for Cardiovascular Prevention and Rehabilitation annual conference, I gave the example of a man who had had a heart attack and been given statins and whose months of disabling muscle pain resolved within a week of stopping taking them. His elation was cut short when his GP told him he must never stop his statin or he could die. When the audience was asked to guess what his risk of death was from stopping the pill for two weeks, the first response was 25%. There were gasps when I revealed it was actually between zero and one in 10,000.
Such statistical and health illiteracy, far from being the exception, is actually the norm. The majority of healthcare professionals seem unable to understand medical literature. One study revealed 70% of those on a training programme failed a simple test on their understanding of evidence-based medicine.
But the reliability of research findings published in medical journals must also be questioned. In his paper How To Survive the Medical Misinformation Mess, Stanford University professor of medicine and statistics John Ioannidis, an authority on scientific integrity, reveals only 7% of more than 60,000 clinical studies analysed passed criteria of being high quality and clinically relevant to patients.
We should also be concerned about the very integrity of medical research on which doctors rely to make clinical decisions. In an international survey of respondents from higher education institutions, 14% admitted to knowing of a colleague who fabricated, falsified or modified data and 34% of scientists report questionable research practices that included selective reporting of clinical outcomes in published research and concealing conflicts of interest.
One prominent Dutch physician, whose work is alleged to have influenced European of Society of Cardiology guidelines on the use of beta blocker drugs in non-cardiac surgery, was dismissed from Erasmus University for “violations in academic integrity”, including using “fictitious data” in research. A study carried out by Darrel Francis at Imperial College estimated that these guidelines increased patient mortality by 27%, resulting in 800,000 excess deaths over eight years across Europe.
The lack of the medical profession’s awareness of the true extent of biased reporting and scientific fraud is underpinned by universities’ and medical journals’ reliance on the belief that research they produce is ethical and accurate. In evidence submitted to the parliamentary science and technology committee, cardiologist Peter Wilmshurst points out they are “as likely to admit the full magnitude of research misconduct as church leaders are to confess the extent of child abuse by priests”.
Pharma companies are not legally bound to sell patients the best treatment, but they are obliged to provide profit for shareholders. Between 2009 and 2014, the industry received fines totalling $13bn for criminal behaviour that included illegal marketing of drugs, hiding data on harms and manipulation of results. As pointed out in a recent BMJ editorial “few systematic changes have occurred to prevent such problems occurring again”.
Earlier this year, the BBC reported on the results of a new cholesterol lowering drug for patients with heart disease, headlining the story “‘Huge advance’ in fighting world’s biggest killer”. Closer scrutiny revealed there was no reduction in death rates from heart disease, no reduction in deaths from any cause, and in European participants in the trial there was no reduction in any non-fatal heart attacks. In fact, there were 18 more deaths in patients who received the drug than those who didn’t.
The battle we face in healthcare is one of “truth versus money”, according to former editor of the New England Journal of Medicine Marcia Angell. After almost two decades editing the journal, she reluctantly concluded that it was no longer possible to trust much of the literature that was published or rely on the authority of physicians or medical guidelines.
The Academy of Medical Sciences has called for greater use of medicines to prevent rather than treat disease. This will be music to the ears of the drug industry, which can exploit a market in treating chronic disease by selling more pills.
Carl Heneghan, director of the Centre of Evidence Based-Medicine at Oxford University, said in response “there are too many people with conflicts of interest taking decisions about policy and the way forward”.
Systemic failure to regulate against the excesses of Big Food and Big Pharma is a false economy. A 2015 report by the investment bank Morgan Stanley revealed that the failure to tackle the “diabesity epidemic” from a high-sugar diet may result in close to 0% economic growth in OECD countries by 2035.
It’s estimated that 20-50% of more than $3tn of healthcare activity in the United States is inappropriate, wasting resources and/or harming patients. According to Peter Gøtzsche, co-founder of the Cochrane Collaboration, , side effects from prescription medications are the third most common cause of death after heart disease and cancer.
The crisis of trust has now reached grassroots doctors and patients, with a report from the Academy of Medical Sciences revealing more than four in five GPs – and two in three members of the public – don’t trust drug company-sponsored research. Could this be a tipping point for real change to wind back the harms of too much medicine contributing to the unnecessary deaths and harm to millions across the globe?
A full public inquiry on the scale of Chilcot into the Iraq war may ultimately be required to overhaul a system where at every level financial interest continues to trump what’s best for patients – not only to improve the quality of care, but to restore trust in medical research. Until then, NHS England, the BMA and the Department of Health must make it a national priority to emphasise to patients that less medicine and healthier lifestyles are the most important solutions to sustaining the NHS.
- Dr Aseem Malhotra is a consultant cardiologist and member of the Academy of Medical Royal Colleges choosing wisely steering group
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