Too few patients ask questions even when they do not understand the explanations given by their doctors. Treatment at public hospitals, superclinics or lack of a regular GP compounds the problem as people treated by "strangers" face the usual barriers encountered trying to communicate with someone newly met. Even more so if they do not speak the same first language.

Time constraints can prevent the treating Doctor teasing out the full story of the patients problems and lack of familiarity (trust factor) may inhibit some people being completely open and frank.

Add to this the frequent problem of 'poor history'. Frequently a Dr will have incomplete, scanty or no details on file. The patient does not always give comprehensive account of (or Drs make sufficient query into) current/past health problems or prescription and/or over the counter, homeopathic, illicit medications they are already taking. Most patients will leave the consultation with a script. They expect it and Drs are looking for a 'solution'. By now readers should begin to understand why the incidence of "Adverse Drug Reaction", sometimes fatal, is so high.

Andrew's advice is very good and I hope the mostly bright folk on this forum who read it will remember and apply. Getting the message to the wider community - and having them understand is a far greater task.

...Very educational. NNT and NNH are now in my vocabulary, that makes for about three million and two acronyms now, already there; which raises the problem of "acronym speak" and its side effects. One being to disengage the patient and confuse the doctor as well apparently.

...About the second time in my life I attended a doctors surgery for a minor problem was a few months ago, the Chemist buoyed my confidence prior to the visit by offering his opinion, my symptoms were probably as a result of cancer.I smiled. Visiting the doctor some years ago, a dim memory, that particular doctor also offered the opinion my complaint was probably cancer, I did not smile: It wasn't!

...But thanks Dr Gunn, When I pay a return visit to the local GP I will definitely drop the occasional acronym in order to disengage him from the computer screen long enough to look me in the eye and tell me it isn't cancer!

Two and a half cheers for Dr. Gunn’s piece.

Two minor quibbles.

First:

How many people do you have to vaccinate in order to avoid one case of polio?

In Australia today: Probably 500+, very considerably plus (NNT much greater than 500)

Even during the height of the epidemic, NNT for the polio vaccine was 100+ though it was about 50 if you considered only children, the most at risk part of the population.

Yet few doctors would advise against having your children vaccinated.

NNT is a very important metric. But it is not the only one to take into account.

Second:

The only reasonable way to avoid polio during the height of the epidemic was through vaccination.

In the case of heart attacks and strokes, for most people in Australia, a bit more physical activity and bit healthier eating will do more to cut the risk that taking statins with ZERO side effects and ZERO cost. I wish Dr. Gunn had mentioned that.

>>Imagine that a new wonder drug has been created. It will help prevent illness and disease – including cancer. I will help you lose excess weight – and keep it off. I will slow the aging process making you look and feel younger than your years. It will give you energy and increase your self-esteem. It will reduce stress, fight depression and anxiety, and put you in a better mood. I will make you stronger and healthier. It will improve your posture, your flexibility, your balance and your endurance. It will even help you sleep better.

Now imagine this drug doesn’t cost a penny and that you can take it sever times a day or just once a day and still see results. In fact you’ll start seeing results within two weeks of your first dose.

Sounds pretty appealing doesn’t it? Would you take it?

This miracle drug is available right now – and you can start taking it today. It’s called exercise.>>

Diane Dahm MD, Jay Smith MD, both from the Mayo Clinic.

Sounds better than statins doesn’t it?

...Preventative medicine "Stevenlmyer" great believer in it, but something always "Gets you" in the end, and it will not prevent polio and the illnesses associated with viral attacks and their side effects. But I get your point, I still 100% support its simplicity. There is also an antidote that will combat much mental illness to, it is called "social engagement"; it uses the same preventative regime of exercise but of the mental type.

hi stevenlmeyers, thanks for the 2.5 cheers!

The article just aimed to raise awareness of how patients and doctors can assess treatments although maybe I should have mentioned that NNT and NNH caculations are largely based on data from drug company sponsored trials. It's almost routine for new drugs to arrive in a blaze of marketing yet ultimately be found to be less effective and more hazardous than initially supposed.

Regarding your quibbles, I didn't intend to imply an NNT over 50 is unacceptable (and certainly not for vaccines which have convenience and herd immunity on their side).

I might also point to other pieces, eg in http://www.onlineopinion.com.au/view.asp?article=9349&page=0

I conclude:

"Incidentally, the NNT for regular exercise to prevent a heart attack is perhaps about three. In other words, compared with high-tech drugs, exercise is vastly more effective at preventing heart attacks and is almost certainly less harmful. No wonder an apocryphal tsar had an interesting solution when he discovered his most disease-ridden province also had the most doctors. He killed the doctors."

And in http://www.onlineopinion.com.au/view.asp?article=9207&page=0

or (the original, complete, better-formatted version)
http://www.rationalist.com.au/archive/83/02-05%20Immunisation%20AGunn.pdf

I discuss polio vaccine:

"Another immunisation success is the virtual elimination of polio. Many of my older patients caught the virus during their childhood in the 1940s and 1950s.

While I excised a skin cancer recently, one man with a withered arm asserted his view of anti-immunisers. He thinks they are insane because he personally witnessed a huge fall in polio infections with widespread immunisation. He is still upset that the immunisation became available a few months too late to prevent his disability.

Polio vaccine did in time, however, suffer a cost-benefit dilemma. The commonly-used Sabin oral vaccine uses a weakened, live polio virus which carries in the vicinity of a one in 2.5 million risk of causing polio. This was used in Australia for decades and eventually, perhaps for years, the tiny risk of the immunisation was greater than the even tinier risk of naturally-occurring disease. Australia has now switched to a more expensive injectable vaccine with no associated risk of causing polio."

The issues with vaccines is that herd immunity is vital for management of the diseases. Because there are people in the community who cannot be vaccinated (because of immune disorders or are too young, etc) herd immunity is the only way to protect these people. If the disease is allowed to freely circulate by those who do not recognise that vaccines have value you end up with preventable deaths in the community.

Cancer treatment is far more complicated because chemotherapy drugs are designed to kill cells. The idea is that the cancer cells are killed faster and more completely because they are more active than many normal cells. Whether chemotherapy will be effective depends on the efficacy of the drugs at killing the cancer cells without killing too many of the normal cells. Doctors may be too ready to suggest chemotherapy when it is unlikely to work. In their defence, some probably do it because there is hope that way, whereas, they know allowing the cancer to take its course will be fatal.

That is not to say there is anything particularly wrong with the article. I always talk to my doctor about his confidence in the treatments versus alternatives.

Hi Dr. Gunn

Sorry, should have checked up on your previous articles before making my comments.

We have reached a sorry state of affairs. To quote Richard Horton, former editor of The Lancet:

>>Journals have devolved into information laundering operations for the pharmaceutical industry*>>

This is a shocking statement coming from a former editor of such a prestigious journal.

I sometimes wonder whether doctors should issue prescriptions with:

Brisk fifteen minute walk b.i.d.

The campaign against smoking his been largely successful. The proportion of adults who smoke has dropped precipitately. But encouraging more physical activity is always put into the too hard basket. I did a spoof piece on this a few weeks ago:

TAXING US INTO GOOD HEALTH

http://forum.onlineopinion.com.au/thread.asp?discussion=4641&page=0

Like your patient I too belong to the generation that remembers the polio epidemic. A dear friend of mine recently gave up the struggle and resigned herself to life in a wheelchair.

*As quoted in PLoS Medicine:
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020138#pmed-0020138-b1

Dr. Gunn,

Great article, but I think we should start with the basics before we worry about NNT's and such like. Only a few months ago I had a GP (not my regular one, thank heavens) offer to write me a prescription of antibiotics for my COLD. :(

To be fair, he probably knew they'd do no good and was making the offer preemptively because of all the halfwit patients who come into his office demanding antibiotics for viral infections. But that's not really an excuse for such quackery - makes you wonder where these folk get their medical degrees.