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Discussion Forum – Previous topics 

Date: Thu, 10 Aug 2006 12:15
– comments:
Topic: Patients self-medicating through internet

I note with interest the story in today's press regarding the purchasing of POM through the internet and the stark warnings given by Philip Severn and Scott Fraser regarding this matter.  As this trend continues it is important to consider some two motivating factors behind patients' purchases of POM from abroad.

As I recall it, the advertisement of medicines from abroad ballooned with licensing of Viagra abroad at a time when it was not available in the UK. Further, the prescribing of Viagra was controlled and limited to only 20% of patients who in many cases, were desperate to try it after many years of impotence. It was then that people realised that control over medication choices need not be given to GPs who are operating within tight budgets and QUANGO control, but rather, back to the patient who in many cases is capable of making that decision based on information readily available on the internet.

Another, similar example of, in my view unnecessary, over control is sleeping aids such as hypnotics which are strictly controlled and regulated by UK GPs.  Myself and many others use hynotics as a lifestyle choice to correct irregular sleep patterns brought on by demanding work patterns so for example, now a 5.30am rise will not lead to three days of poor sleep, insomnia and exhaustion but will be facilitated by a 9.30pm bedtime aided by Zopiclone or Stillnoct.  In my case, I use around 30 7.5mg Zopiclone per year and it has transformed my life through the regulation of my sleep pattern.

A second reason why people might choose to buy medicines over the internet relates to patient/doctor confidentiality or rather the lack of in certain situations.  In many instances where a job offer is subject to medical, a patient must first give permission to his/her GP for their medical records to be made available to the prospective employer.  That a patient should have to consent to their private medical records being viewed in order to obtain employment seems ludicrous to me as it breaches the patient/doctor confidentiality on which many patients rely.  As a result of this, I purchased Citalopram from abroad for a period of 2 years during which I was able to self-medicate and successfully recover from a bout of  situational depression without that very sensitive information being made available to my employer on demand.

The case of the woman self-medicating on Prednisolone highlights very clearly the dangers of patients without medical knowledge making these types of decisions.  Rather than reacting to this trend by looking at ways to close down the sale of POMs on the internet (which is doomed to failure), it would be most refreshing instead to see the BMA and British Doctors looking a the reasons why patients are resorting to the internet with a view to evolving current practice in these areas.

Name and address withheld.

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Date: Thu, 10 Aug 2006 12:15
Zoe Bremer comments:
Topic: American Health Insurance

I think I am right in saying that health insurance is much
cheaper, with lower excess fees, than in the USA, even if it covers people while they are over there. Why, therefore, are British and other EU mutuals not promoting their health insurance services in the USA?

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Date: Tue, 6 Jun 2006 15:31
Dougal Jeffries comments:
Topic: Shared decision making

I enjoyed Glyn Elwyn's editorial in this month's issue, but wanted to provoke some discussion about maximising the placebo effect. If we are ready to acknowledge that this effect is a powerful force for recovery, or at least symptomatic improvement, in many conditions; and that furthermore its effectiveness can be enhanced by 'talking up' whatever intervention we may be suggesting, how do we reconcile this with offering a truly informed choice of options?  For we are also supposed, according to the prevailing orthodoxy of shared decision-making as described by Elwyn, to be admitting
uncertainty, and presumably to be evaluating the evidence for and against all alternative options. This must surely have the effect of diluting any placebo effect. To complicate matters still further, maybe we should also be explaining just how powerful the placebo effect itself can be, at the risk that this explanation will thereby diminish that very power!

I think that most of us naturally occupy some middle ground in this quagmire of logical contradictions. Thus, in dealing with a patient with neck pain, I know from a fair amount of study that no treatments are supported by strong evidence; I also know that most patients will get better whatever I do, that occasionally I can give prompt relief by manipulation, and that my very rudimentary acupuncture skills are often followed (temporally, if not causally) by major improvement. I will therefore sound out the alternatives
- physiotherapy and analgesics included - and form some sense of the patient's preferences. Once we have agreed on a plan, I will be as psoitive as I feel is respectable about it.  What I shrink from doing is setting out by summarising the overwhelmingly negative evidence base for all possible treatments, though at first sight this might be the most honest and 'empowering' approach.

If I have made myself understood to any readers, I should be most interested in their responses.

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Date: Sat, 3 Jun 2006 08:26
Ian Rubenstein comments:
Topic : Increase in antidepressant prescribing in Scotland

Why on earth are the authors of this paper so mystified
about the increase in antidepressant prescribing?

Anyone in practice during the 90s will remember the combined RCGP/RCPscyh "Defeat Depression" campaign. John Horder came out of the closet and talked about his own depressive illness. At the time we were all exhorted to diagnose and vigorously treat with antidepressants as much as possible (this was a very strong message from the RCGPs lip service was paid to other forms of treatment but actually the message was don't be afraid to use antidepressants in high dosage).

Anyway, as every drug rep and advertising executive knows, campaigns can be an effective way of changing behaviour.

So, no mystery there.

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Date: Sat, 3 Jun 2006 08:06
Ian Rubenstein comments:
Topic: Spiritual Healing and Asthma

I read the above paper with interest and have the following coments to make:

As far as Spiritualists are concerned it is not the healer who heals but someone who is merely a conduit for healing from 'spirit'. I just wonder what, in their terms, the validity of using a 'proper' healer and a 'sham' healer would be. The methodology assumes that it is the person who is doing the healing: change the person and you have altered the conditions. However, if it is merely the technique which heals (i.e. allowing oneself to be a conduit) then in fact the three-armed study may have been a two-armed study with no control. Presumably a spiritualist would say all that has changed is the conduit, not the modality! Now one may counter this by saying that the intention is different and furthermore the training is different. However a good method actor who is playing a role would be a very highly trained and empathic person: perhaps even more empathic than your average healer, which might have some effect upon any presumed spiritual influence.

Spiritualists would counter the negative findings by saying that the reason for the Hawthorne effect is that it is always operative in any
doctor-patient interaction: it's the milieu within which we all operate.

I realise that this takes us beyond the realm of currently possible
scientific investigation: you'd have to find a way of shielding presumed spiritual influence completely using something like a psychic Faraday cage!

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Date: Fri, 2 Jun 2006 10:11
Topic: voluntary euthanasia
Chris Wayte comments:
David Jewell asked if the medical profession were out of
touch with public mood, in the Focus column in the June BJGP issue. Public mood is very difficult to gauge, and surveys are very open to bias depending on the questions asked, so surveys suggesting that "the public" are in favour of voluntary euthanasia aren't necessarily correct.

Even if a survery was accurate, the opinions being reflected may not be right. It is possible to produce opinion polls saying that the majority of people are in favour of restoring the death penalty. Does this make it right to restore the death penalty?

Another important factor is that, if voluntary euthanasia was ever
introduced, doctors would be expected to carry out the action. Is it right for one group (the voluntary euthanasia lobby)to impose a duty on others (doctors) to do something that they believe to be wrong?

The decision by the Lords to reject the Joffe Bill is in line with the
majority of the medical profession's views, and as David Jewell says, why should the Joffe Bill be given further parliamentary time when it has been conclusively rejected?

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Date: 28 May 2006 17:16
Dr John AJ Macleod comments:
Topic: College name
The RCGP desrves immense credit for the lead that it has given the rest of the world. When it was founded the name College of General Practitioners was appropriate. However things have advanced. Some years ago, I enjoyed sitting on College Council as a deputy for the North of Scotland. Several times there were suggestions that people other than GPs should be eligible for membership. I consider that it is time for the RCGP to consider changing its name to Royal College of General or Family Practice. I give two specific reasons or this.

1.Much of the work that was purely done by GPs at the time of founding is now done by others.
2. The world wide sister colleges that have been developed under the influence of the RCGP are virtually all Colleges of General Practice or Family Practice and thus the "new" workers can be members.

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In the 2006 February BJGP Jim Cox accuses general practitioners of having abandoned their historic role as gatekeepers, that has up till now been regarded as one of the keystones of UK general practice.  Is he right?  And if he is, does it matter?

Date: Fri, 7 Apr 2006 15:36
David Lewis Comments:
Dr Cox is, I think correct. Philosophically we have not abandoned the role of gatekeeper, but the system in which we work has created alternative ways to access primary healthcare while undermining our professional autonomy with performance based practices. The end result is that GPs appear to have abandoned the gatekeeper role.