The need for continuing education of the prescriber

The Millennium will be seen as an important time of change in the doctor-patient relationship. Until very recently, many patients, male and female, expected not only advice from their doctor, but also to be told which treatment would be best for them. This paternalistic approach, however, is rapidly disappearing. Nowadays, early post-menopausal women expect to make decisions about their treatment, after being fully informed of all the possible benefits and risks. Provision for this requires the doctor to keep abreast of the literature. Occasionally, new data are released that challenge established beliefs. It was thought, for example, that hormone replacement therapy (HRT) would reduce the risk of coronary heart disease. This still applies to apparently fit and healthy women but data from the Heart and Estrogen/progestin Replacement Study (HERS) have shown that the use of HRT in women with established risk factors for coronary heart disease increases mortality in the short term. A protective effect of HRT on the risk of coronary heart disease was not observed until after 2-3 years of treatment. Patient access to medical information has been revolutionized during the last decade. The availability of books, magazines and newspaper articles, which have always been an important source of patient information, has greatly increased. In addition, the Internet has transformed patient knowledge. According to surveys, these forms of communication provide the major source of information for 50% of women seeking advice about HRT. Indeed, the patient is often aware of the latest medical information before her doctor, possibly because she has more time. With such a large readership, these forms of communication have to report accurately. Unfortunately, they frequently do not and errors in reporting change the emphasis of a piece of medical research. The result is women are frightened and continuance suffers. It is worth remembering that 'bad news', suitably publicized, sells more newspapers and magazines than 'good news'. Competition is growing for 'alternative' products. 'Natural' treatments are 'in'. These treatments are widely claimed to reduce menopausal complaints in older patients and patients are keen to take them. But where is the evidence of efficacy and safety from robust and rigorous studies? All too often it is lacking. The doctor therefore has to advise the patient accurately about products for their treatment, and may also have to provide an opinion on 'alternative' remedies. Knowledge of alternative medical literature is therefore becoming essential. If doctors wish to continue to be respected by patients, they must remain knowledgeable and communicate their knowledge in an unbiased manner. They must emphasize the benefits and risks of different treatments according to the concerns of the patient. Failure of the doctor to provide this service will result not only in loss of respect, but alas, too often, in medico-legal consequences.