In Scotland, my GP Practice is a Contractor for the Scottish Government, with powers delegated from the UK Government.
It has “Targets” to meet to get money.
I understand that there is a Target for the %age of over 45s being prescribed statins.
This doesn’t help patient-doctor relations.
( The doctor I’ve seen the last few years doesn’t mention them.)
Perhaps in a socialised medical framework they decided universal testing on these conditions would not be cost effective?
You can get a colonoscopy on the NHS, but as with many tests there’s a risk of it going wrong – in this case perforating the bowel. It happens one in every few thousand colonoscopies, more or less – so it would typically only be done if there was a good reason for it such as symptoms of possible cancer or a strong family history of bowel cancer. Then the risks of not doing the test will clearly outweigh the risks of doing the test.
PSA is a borderline case – the potential harm is that as a test it gives lots of false positives, leading to unnecessary investigations and overtreatment. It also gives some false negatives. The majority of men die with prostate cancer, but far fewer men die of prostate cancer, so even if you discover that someone has mild prostate cancer, investigating and treating it isn’t necessarily doing them any favours and can lead to problems such as infections and erectile dysfunction. On the other hand the test will occasionally save lives. Hence the opt-in nature of the test on the NHS.
It’s a problem you see fairly often in medicine. Someone does a test that isn’t really necessary and an abnormal result leads to a cascade of investigation, admissions and often as not it turns out to be a storm in a teacup. My bugbear is D-Dimers which are a test for looking for pulmonary emboli which can cause chest pain and shortness of breath. If the nurses or junior doctors request a D-Dimer in a young girl who plays hockey and has had a few bumps or scrapes over the previous week it will invariably come back positive. This tends to lead to a particular sort of CT scan which some people estimate causes 1 breast or lung cancer for every 70 or so scans in female patients of that age group. Locally, you can’t get them done overnight so it normally involves a hospital stay and injections of anticoagulants whilst waiting for the test.
1 in 70 is really quite a lot. I’d guesstimate that most hospital doctors working in A&E or the medical take will organise at least that number of similar tests in youngish patients over the course of a career. There’s one girl I know of who has had two of these CT scans. One saved her life showing a massive PE. The other showed a chest infection. Medicine ultimately is about betting with other people’s lives. Oh for the honesty of sitting at the pointy end of an airliner, taking on an honest share of the risks.
PSA is a borderline case – the potential harm is that as a test it gives lots of false positives, leading to unnecessary investigations and overtreatment. It also gives some false negatives. The majority of men die with prostate cancer, but far fewer men die of prostate cancer, so even if you discover that someone has mild prostate cancer, investigating and treating it isn’t necessarily doing them any favours and can lead to problems such as infections and erectile dysfunction. On the other hand the test will occasionally save lives. Hence the opt-in nature of the test on the NHS.
This again has a difficulty because while only ~ 3% of men die of PC, rather more than that get diagnosed with it when they have symptoms by which time it is usually too late and the whole thing has to come out, with a ~80% chance of no sex life ever and a ~20% chance of incontinence (1x or 2x). But these men, with a much reduced quality of life, don’t die and thus don’t feature in the population stats… Do you want to be one of them?
I had the whole of my local GP practice discourage me very hard for several years (occassionally with real bullsh*it) but eventually after meeting N men who had proper PC I decided I had enough and got the test. It came back c. 5 and the GP practice went into panic mode. Maybe they thought I would sue… I just got on with it myself and within 24hrs I had a £1000 3T MRI done in London and got myself signed up with Emberton (following a pointer from another pilot with PC who researched it) and for another £250 I knew I was probably OK, but remained on the scheme and am still on it 6 years later. All good… so far. Another MRI a year later to see if anything was changing. A PSA test every 6 months, to monitor trends. All free on the NHS. Obviously both CAA and FAA are happy too (otherwise I would not be writing about it 
). I call it peace of mind; others would prefer to not know.
Then I bumped into another pilot whose initial PSA was 8. Without a re-test, his GP sent him for this I told him his GP was mad, and sent him the above stuff. I never heard back and maybe he was among the ~90% of people who don’t really care… You could get 8 due to various reasons, including possibly riding a bike for a few hrs and having sex afterwards, on the morning of the test 
(kidding, mainly).
As for false negatives, according to Emberton, if your PSA is below 0.5 then the chances of developing PC is 1/6000, which should be good enough to forget about it.
There should be little or no over-treatment if the MRI is used correctly. So there really is very little to lose. But you will have to push it through your GP practice, and pay for the hi-res MRI and pay for a specialist to look at it.
I suppose the bottom line is that the system will be seen as delivering a bad service to the 10% who get clued-up and can make the judgements. We probably have those 10% disproportionately represented here. Let’s face it, getting into flying does need a bit of an obscessive personality. The other 90% will sometimes get the service which, to use the phrase used in politics, they deserve. But a doctor has to work with the whole 100%. And resources are finite.
Back to statins, the long term picture may bring surprises due to e.g. this The evidence seems to be thin (also for dementia) but then they have not been around for long.
Peter wrote:
I suppose the bottom line is that the system will be seen as delivering a bad service to the 10% who get clued-up and can make the judgements. We probably have those 10% disproportionately represented here. Let’s face it, getting into flying does need a bit of an obscessive personality. The other 90% will sometimes get the service which, to use the phrase used in politics, they deserve. But a doctor has to work with the whole 100%. And resources are finite.
My father is alive today in his late 80s because of PSA testing. His younger brother is dead today because he never had a PSA test, in fact all my father’s brothers except the youngest (20 years his junior) are dead today as a result of inadequate medical care. I won’t speculate on the reasons and justifications, but I will make sure it doesn’t happen to me. You could call that obsessive or just responsible, your choice
The guy who did my colonoscopy has done literally thousands of them, and does them all day long. What a way to make a living, eh? He doesn’t make many mistakes or have many problems, practice makes perfect. I figured that out by making an appointment and talking to him about it. I’m not a statistic and neither is he.
Update on statins – Scottish NHS site current info:
“Alternatives to statins
If you’re at risk of developing CVD in the near future, your doctor will usually recommend lifestyle measures to reduce this risk before they suggest that you take statins.
Lifestyle measures that can reduce your cholesterol level and CVD risk include:
eating a healthy, balanced diet
exercising regularly
maintaining a healthy weight
limiting the amount of alcohol you drink
stopping smoking"
I eat healthy, balanced diet, excercise regularly (on average run 80 to 100 km a month), maintain healthy weight, drink rarely and not much, don’t smoke – yet after last medical (few days ago), doctor recomended statins due to cholesterol level being slightly above margin and some blood-vessels plaque found on ultrasound image. I’m discussing this topic with my brother who is physician and specialst at occupational and sports medicine.
Emir wrote:
I’m discussing this topic with my brother who is physician and specialst at occupational and sports medicine.
After detaily examining the results and sending me to some additional checks he completely ruled out statins as totally needless in my case. He phoned doctor who recomended to get the explanation and get nothing supported with arguments, it was rather “I thought it would be ok to try …”. As usual, go for 2nd (and 3rd if needed) opinion and make informed decision. I’m lucky to have a brother with vast experience
