The idea the there is gold in them thar pills is, one might say, as old as the hills: the book on the left was published in 1975. But it sure is a rum old business. Dr No’s last post highlighted the paradox that, even for drugs that do work, for most patients, most drugs don’t work. This naturally enough in today’s world of evidence based medicine begs the question: why do doctors prescribe, on the industrial scale they do, when the evidence shows most of the time, most drugs don’t work? The answer, Dr No suspects, not necessarily quite so straight forward as at first it may seem, and may even have more to do with blind faith than scientific evidence.
Whatever the possible reasons for prescribing on such a scale, which Dr No will come to shortly, the bulk of it is done in primary care. GPs account for around two thirds of the NHS medicines bill, covering an eye-watering 961.5 million items – which works out at 18.3 items per person per year – in England in 2011. Given that GPs account for two thirds of the bill, and average individual item costs are mostly lower in primary care, the proportion of all prescriptions issued by GPs will be even greater – let us guesstimate three quarters. In numerical and cost terms, it is overwhelmingly GPs who are Big Pharma’s little helpers. Indeed, Big Pharma wouldn’t be anything like as Big as it is without its little helpers – which is all the more reason to ask: why do the little helpers help so willingly when, most of the time, most drugs don’t work?
The first possibility is simply that GPs, in the round, are not the brightest crayons in the box. The nice lady drug rep with high heels and rocket bra gives the doctor a sharp new pencil with Viagra written on it; and so the doctor prescribes Viagra (the NNT for which, as it happens, isn’t too bad at all, at around two: only a couple of men need take it for one to get a bigger handle back on his pan). Be that as it may, in the past, sexy repettes – Dr No has known surgeries where one couldn’t move for drug reps, not to mention panhandles – and bribes were used to sell drugs, but today, tighter rules on how drug companies peddle their wares mean this influence on prescribing peaked some time ago, and is now in decline.
The second possible reason, which Dr No has touched on in previous posts, is that GPs prescribe as much as they do because that is what they have always done, in that today’s GP in the lineal descendant of yesterday’s apothecary, or corner-shop chemist. The shopper/patient expects a pill, and the shop-keeper/doctor provides. All that caring and sharing mumbo-jumbo is so much window-dressing: behind the closed shop door, the majority of transaction remain, as they always have done, shopper-provider transactions. As Maslow might have said, when all you have is a prescription pad, everyone looks like a patient. But is this enough to explain nearly one thousand million prescriptions per year in England alone? Dr No suspects not: something stronger must be at play to generate that colossal number.
The third possible reason – and Dr No mentions it largely to rule it out – is that GPs really do understand NNTs, and so know they must, to use an example from the last post, give sixty patients a statin for one heart attack to be averted. They understand that while evidence based medicine tells us what works for some patients, it also tells us that, for most patients, most drugs don’t work; yet the only way to get any benefit at all is to prescribe on an industrial scale. But most doctors, let alone GPs, even when they do understand an NNT – many do not – don’t routinely incorporate it into their practice. Instead, the doctor believes (as indeed, to be fair, do most patients who take medication) that this drug particular works, for this particular patient; even when, as we know, most of the time, it doesn’t.
To believe in something in the absence of evidence has a name: faith. Most doctors, especially those who reach for the pen rather than the knife, Dr No suggests, believe in medicines in much the same way that priests believe in God. For each, the entity, be it a medicine or deity, is so core to the enterprise that not to have faith in it is unthinkable. Doubts maybe, but at the end of each day, the faithful return to their faith; and as is the way with faith, it can removeth all mountains, not to mention launcheth a thousand million prescriptions, for with faith comes drive. Doctors can’t help but prescribe. As the Talmud has it, more than the calf desires to suckle, the cow desires to nurse.
In Bad Pharma, Ben Goldacre paints a picture of an evil industry running rings round well-intentioned but gullible doctors. Dr No is not so sure it is as simple as that. The distorting effect of publication bias – burying bad news – has been recognised for decades, such that the scandal is not that it happens, but that it is still happening. Could it be, Dr No wonders, that doctors’ blind faith in drugs means they cannot help but be Big Pharma’s willing little helpers? They simply don’t want to know that most of the time, most drugs don’t work. As patients, we might well want to ask: when does blind faith becomes inadvertent complicity?