The current public view of modern medicines, ably fuelled by the mass media, is a compound of vague expectation of 'miracle' cures with outrage when anything goes wrong. It is also unreasonable to expect the public to trust the medical profession (in collaboration with the pharmaceutical industry) to the extent of leaving to them all drug matters.
The public wants benefits without risks and without having to alter its unhealthy ways of living; a deeply irrational position. But it is easy to understand that a person who has taken into his body a chemical with intent to relieve suffering, whether or not it is self-induced, can feel profound anger when harm ensues.
Expectations have been raised and now, at the beginning of the 21st century, with the manifest achievement of technology all around us, the naive expectation that happiness can be a part of the technological package is increasingly seen to be unrealisable.
Patients are aware that there is justifiable criticism of the standards of medical prescribing, indeed doctors are in the forefront of this; as well as justifiable criticism of promotional practices of the profitably rich, aggressive, international pharmaceutical industry.
There are obvious areas where some remedial action is possible:
• Improvement of prescribing by doctors, including better communication with patients, i.e. doctors must learn to feel that introduction of foreign chemicals into their patients' bodies is a serious matter, which the majority do not seem to feel at present.10
• Introduction of no-fault compensation schemes for serious drug injury (some countries already have these; see p. 10).
• Informed public discussion of the issues between the medical profession, industrial drug developers, politicians and other 'opinion-formers' in society, and patients (the public).
• Restraint in promotion by the pharmaceutical industry including self-control by both industry and doctors in their necessarily close relationship, which the public is inclined to regard as a conspiracy, especially when the gifts and payments made to doctors get into the news.
If restraint by both parties is not forthcoming, and it may not be, then both doctor and industry can expect more control to be exercised over them by politicians responding to public demand. If doctors do not want their prescribing to be restricted, they should prescribe better.
It is a salutary thought that each year medical errors kill an estimated 44 000-98 000 Americans (more than die in motor vehicle accidents) and injure 1000 000.11 Evidence from both the USA and Australia shows that among inpatients about half of the injuries caused by medical mismanagement result from surgery but that therapeutic mishaps
10 Doctors who seek to exculpate themselves from serious, even fatal, prescribing errors by appealing to undoubted difficulties presented by the information explosion of modern times, allied to pressures of work, are unlikely to get sympathy, and increasingly are more likely to be told, 'If you can't stand the heat, get out of the kitchen' (a dictum attributed to Harry S Truman, US President 1948-52, though he assigns it to US Army General Harry Vaughn). Pharmacists and nurses stand ready and willing to relieve doctors of the burden of prescribing.
11 Kohn L, Corrigan J, Donaldson M (eds) for the Committee on Quality of Health Care in America, Institute of Medicine
2000 To err is human: building a safer health system.
Washington: National Academy Press.
and diagnostic errors are the next most common. In one survey of adverse drug events, 1% were fatal, 12% life threatening, 30% serious and 57% significant.12 About half of the life threatening and serious events were preventable. Errors of prescribing account for one half and of administering drugs for one quarter of these. Inevitably, a proportion of lapses result in litigation and in the UK, 20-25% of complaints received by the medical defence organisations about general practitioners follow medication errors.
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