HEALTH / Second Opinion

SOME years back one of my elderly relatives had a couple of dizzy turns and was referred to a consultant at a London hospital. He examined her and sent her home without making any arrangement to see her again. He ordered no blood tests and recommended no treatment: he told her she was perfectly well and she believed him. And she remained well.

Nowadays someone with similar complaints would almost certainly be given a whole battery of tests and scans. She would probably be advised to take a daily dose of aspirin, to reduce the salt and fat in her diet, and to take more exercise. This would marginally reduce her risk of having a stroke, but she would also be made to think of herself as unwell and in need of lifelong 'check-ups'.

Interventionist medicine became fashionable in the last decade, when it fitted the mood of the times. There are, indeed, good arguments for encouraging people over the age of 50 to be screened for cancers, high blood pressure and eye disorders. But the number of tests of proven value is quite small, and searching for abnormalities may not always be a good idea. Medical journals increasingly publish debates about the best management for people found to have slightly abnormal test results. Often the consensus is that nothing need be done except 'reassure the patient'. This may be unrealistic. Someone who has been told the result of a test is abnormal is going to need an awful lot of reassurance to convince them that nothing need be done about it.

The pendulum is, however, beginning to swing back. Searching for symptomless diseases is seen to be justified for only a handful of well-defined conditions. Doctors are also being asked to look more carefully at the treatments they offer for chronic disorders. For example, a recent review of treatments for multiple sclerosis concluded that none of the hi- tech innovations of the 1980s - such as removing antibodies from the blood by plasmapheresis - had proved of any value and the same was true of low-tech approaches such as adding various oils to or excluding gluten from the diet. For most MS sufferers, simple physiotherapy helps provide the boost to morale that comes from something being done.

Around the world, technically advanced countries are struggling to restrain the growth of expenditure on health care for their ageing populations. As the accountants have moved in, questions have been asked which should have been asked before. How effective is this treatment? How reliable is that test? How many people must be screened to detect one extra case of a disease, and how good is the evidence that early detection increases the chances of cure?

A hundred years ago, when medical science had so few effective treatments to offer, the best physicians were those with the confidence and charisma to do nothing. Nowadays, with science offering ever more intervention, patients may need the protection of doctors who are prepared to do the same.