On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.8 Cape Town Aug. 2008
FROM THE EDITOR
J P de V van Niekerk
I signed my father out of hospital and took him back to his retirement home, as was his wish. Following a near-death event from which had recovered he was fine and cheerful but apologetic about causing trouble and was awaiting a battery of tests. He died the next morning at his home and in my presence at the age of 93 years. He was not in a strange bed and surroundings, had not had invasive tests and was possibly spared the indignity of death with tubes, catheters and other end-of-life interventions. Family who recently faced a similar situation with their mother, who had had a good innings but was declining in hospital, felt burdened about their potential decisions. My suggestion to them was that acceptance rather than a decision was called for. In the USA a large slice of the health care budget is spent in frenetic and futile end-of-life medical activities, and in South Africa we are often guilty of the same.
Doctors often feel pressurised to do something for every patient. Apart from satisfying our own needs this compulsion is also fuelled by our patients, whose expectations are disappointed if they feel that nothing or too little is being done for them. Medical practice is strewn with examples of procedures that have been abandoned when shown to be ineffective or harmful. Today too doctors and the public can often do much better by following the evidence rather than relying on myth and belief. Here are some examples.
As a child I suffered regular doses of castor oil and phenolphthalein (at least the latter was disguised with chocolate flavour) because of the belief at the time that a periodic bowel clear-out was healthy. For the same reason periodic enemas had been in vogue (and are still offered in 'health' spas1). Fortunately we now appreciate that these practices are harmful and that the bowel with its various active cells and chemicals and its mucus-lined walls is an exquisite processor of food and rarely needs help other than a prudent diet. Besides, one of life's less expressed and appreciated pleasures is to unburden oneself naturally!
Paediatric cough and cold medications are prescribed and obtained over the counter for the slightest cough or sniffle. Such preparations may contain various combinations of antihistamines, decongestants, antitussives and expectorants. A recent paper in the New England Journal of Medicine1 challenged this practice. Randomised studies have shown no meaningful differences between the active drugs and placebo. However, serious adverse effects have been associated with accidental overdose, inadvertent misuse, and drug-drug or drug-host interactions in children given standard doses. Despite this, parental pressure and slick sales talk from the manufacturers will make it hard to change our behaviour in this regard.
One of the most serious medical maladministrations is the ready use of antibiotics for the most trivial of complaints. It is well known that antibiotics are not effective in viral upper respiratory infections, yet repeated studies show that they continue to be abused in this way. South Africa has been shaken by the appearance in large numbers of extensively drug resistant (XDR) tuberculosis. In this journal two papers address the serious problem of the emergence of extensive drug resistance among Gram-negative bacilli in South Africa.2,3 The emergence of XDR organisms has much to do with antibiotic abuse and cries out for strong self- and external regulatory action.
Backache is one of the commonest symptoms: 'the world is divided into those who have backache and those who will get it'. For the vast majority it has been shown that analgesics and continuing activity provide the best outcomes. Yet endless hours of work are lost and recovery hampered by prescribing bed rest and laying people off work for weeks.
The world, including South Africa, is undergoing huge financial upheavals due to easy credit. Houses, fancy cars and luxury goods have been bought without consideration of payback time. We consume energy and other resources at a rate that will leave our progeny with a much depleted and harmed world; eat ourselves into the obesity epidemic; and proliferate as if the planet has an endless capacity to carry humankind. Our excessive consumption and demand for instant gratification is often reflected in the way that we practise medicine.
We will all benefit from paying more attention to the evidence, and from re-learning the virtues of doing nothing harmful and patience in allowing events to take their natural course.
1. Sharfstein JM, North M, Serwint JR. Over the counter but no longer under the radar - pediatric cough and cold medications. N Engl J Med 2007; 357: 2321-2324. [ Links ]
2. Brin A, Feldman C, Richards G, Moolman J, Senekal M Emergence of extensive drug resistance (XDR) among Gram-negative bacilli in South Africa looms nearer. S Afr Med J 2008; 98. [ Links ]....
3. Perovic O, Koornhof HJ, Crewe-Brown HH, Duse AG, Van Nierop W, Galpin JS. Pseudomonas aeruginosa bacteraemia in an academic hospital in South Africa. S Afr Med J 2008; 98:. [ Links ]....