There is increasing concern being raised in the media and professional bodies around unproven treatments in reproductive medicine. Whilst a measured response is necessary in order to ensure that clinical freedom and patient autonomy are maintained and that genuine innovation is not quashed at source, professionals working in this field have a duty of care to provide the best treatment possible for their patients safely and effectively.
That duty of care is implicit in the GMC Guidance for Doctors and should be expected of the whole multidisciplinary team. This point is especially important in a specialty where key leaders and managers in an organisation are often not GMC registered medics.
Reproductive medicine has suffered greatly over many years of low prioritisation by commissioners and a highly competitive private sector has developed particularly for tertiary services such as IVF. Privately or self-funded patients may be treated in NHS based centres, purely private stand-alone units or, increasingly, in a centre comprising part of a fully commercialised group.
In some regions, perhaps as a result of greater numbers of patients with personal affluence or a broader more cosmopolitan clientele, including international patients attracted to excellent UK health care, the competition between such centres/conglomerates is high.
Alongside this there is much about reproductive medicine – specifically implantation, early embryology and early pregnancy and their complex interrelationships, which are extremely difficult to research and until there is a really good basic understanding of a particular area it is impossible to make truly rational treatment decisions.
Coupled with a highly motivated, well-informed patient group suffering the injustice of being denied NHS-funded treatment, there is a toxic mix of the pressure to “try” something (possibly something different from the clinic down the road), the desire to “do” something – clinicians want to help their patients and satisfy their need for action - and commercial pressure – the need to stay in business.
Early introduction of a technology, before proper validation has been done, – PGS, timelapse, endometrial scratch or the use of “just in case” medicine – ranging from empirical use of fairly (but not totally) innocuous drugs – aspirin for example through to complex regimes of high dose steroids, aspirin and anticoagulants and multiple others taken recurrently, cycle by cycle, with potential for significant harm, may make commercial sense in a competitive market but cannot be advocated for safe and effective introduction.
Certainly significant changes in practice introduced into NHS services will go through a number of levels of scrutiny depending on their complexity and expense and would not be entertained without convincing arguments for their use. Commercial promotion can undermine those high values.
It is not uncommon for excellent NHS centres to be derided as inadequate or poor quality because they do not offer treatment that could be “paid for” in the private sector or for highly qualified NHS practitioners to be considered “non-expert” because they do not offer such treatments. It may not be in the interest of private clinicians to correct such misconceptions and sadly it is sometimes those selfsame NHS staff who practice differently in their private clinics.
Reproductive medicine is not alone in dealing with treatments that lack strong evidence. There are many treatments that have grown up in many specialties where classical randomised controlled trials are either impossible to do or have not been done and yet they have moved into practice.
It is our duty as doctors to continue to review what evidence there is and consider practice change appropriately. Medical training quite rightly includes the ability to understand and critique research papers and all NHS Consultants are expected to be involved in research to some degree.
The drive to have a family is immense and one of the problems in dealing with couples or individuals needing investigation and /or treatment is the uncertainty around an embryo’s ability to make a baby. In natural conceptions a large proportion of embryos do not because they simply don’t have the capacity to do so. We will never be in a position to give certainty. Is it better then to be honest about this, manage expectations and avoid empirical treatments or to “add-in” extra elements to treatment because they sound like they might be helpful even if that means an additional cost to the patient (after all it is their “choice” to spend that money) or the organisation?
This is not a yes or no answer however I would argue that this is not a choice in the way that one might choose a softer mattress in the hope that sleep may be improved when the rep says “it’s not called Dream-Better for nothing”!
Medicine is a highly respected profession and our non-medical teammates aspire to and indeed receive that same respect. Having a collaborative approach with patients and giving patients choice is not the same as opening up the formulary and allowing them to choose what they fancy.
The use of empirical treatment where, crucially, there is lack of evidence rather than evidence of no benefit remains a decision to be judged jointly and individually taking into account individual circumstances and potential risks.
There remains an art to medicine and clinical freedom is a significant part of this. That allows for a trusted doctor to work with integrity to provide best advice and to tailor that to individual patient needs. That does of course also include the potential to explain why there is no test or treatment that will help and the absolute need then to make provision to support the “loss” that accompanies that understanding. Ill-advised treatment given because of the inability or reluctance to give that advice is poor medicine. If commercial pressure rather than good medical practice is driving more practitioners to undertake such treatments then this has reached its current pinnacle in reproductive medicine.
If the move to the commercial sector, which is so advanced in our specialty, is indicative of life outside the NHS then I, for one, hope that we can protect it for as long as possible.
Dr Jane Stewart is chair of the British Fertility Society