A couple of weeks ago Pat had some chest pain. It was unclear if her pain was indigestion, heartburn, or, perhaps, something more serious. But that’s o.k. In these enlightened times we have “pathways of care” to enable us to sift such problems.
So Pat found herself shunted off down the Yellow Brick Road to Oz… er, the Rapid Access Chest Pain clinic. They did a battery of tests, including and exercise EKG*. All were inconclusive.
In case you were wondering, that means that the RACPC has not been able to show that Pat has heart disease. But, in these enlightened times, this does not mean Pat is out of the woods. You see, the way the pathway works, if you have conclusive tests, i.e. proven heart disease, then to get whisked straight from clinic to Cardiology Out Patients to having a stent put in (where possible) before you can say “myocardial ischaemia”. And you get put on lots of drugs to “save” your life.
But if, as with Pat, the tests do not prove you have heart disease, well you still might have it anyhow, so instead of all the tedious mucking about actually making sure one way or the other, you just get put on lots of drugs anyway, “just in case”. Pat has been told she must come and see us to start her meds A.S.A.P. These are to include a beta blocker (recent headlines reporting these drugs are less good at preventing heart disease and so should not be used without a compelling reason) and a statin (to lower cholesterol- can lead to deranged liver function and rarely to muscle wasting).
Now, call me old fashioned, but before I start a patient on long term medication with a significant side effect profile, I would at least like a clear indication, and in the case of the statin a baseline blood test to monitor her liver function BEFORE she starts, so that when her liver function is abnormal on the statin (as it will inevitably be) I can be sure it was in fact normal before the treatment began. The only problem is, poor Pat is now scared she may drop down dead of a heart attack before she gets to start her treatment.
Unfortunately, the RACPC neglected to tell her that though we feel statins are an important part of the preventive treatment for patients with established heart disease risk, even where this is the case (which we as yet have no reason to suspect is so for her) we have to treat eighty patients to prevent one cardiac death.
Somehow we seem to have lost all sense of proportion in managing medical risk. Intriguingly this is happening as we see the drug companies more and more involved in training the Nurse Practitioners who run a lot of the “Rapid Access” diagnostic facilities.
* yes you read it right. I’m actually with the Americans on his one (actually of course it ought to be “epsilon kappa gamma” but EKG has to suffice to save all the mucking about with fonts etc.).