The world is changing fast and to keep up you need local knowledge with global context.
By Marika Sboros
Doctors have always had a name for it: iatrogenic disease, from the Greek word, iatros (doctor). It means doctor-caused disease. It’s a fancy name for doctor error.
Its incidence is unacceptably high worldwide, given that doctors are supposed to heal patients, not harm them. In the US it is the third leading cause of death.
It is the focus of a groundbreaking Choosing Wisely campaign launched in the UK by the Academy of Medical Royal Colleges. It aims to protect patients from the harm caused by “too much medicine”, and stop doctors from being life-takers instead of life-savers.
Choosing Wisely is an initiative developed in the US and Canada. It has become an international campaign, as other countries, including Australia, Germany, Italy, Japan, Netherlands, and Switzerland, have taken it on board.
The authors of a breakthrough analysis in the British Medical Journal, say it’s “a clear sign that wasteful medical practices are a problem for all health systems”.
The analysis, titled Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine, is led by top British cardiologist Dr Aseem Malhotra, a consultant clinical associate of the Academy. Co-authors include two of the arguably most important doctors in the UK: current Academy chair, forensic psychiatric professor and dame Sue Bailey, and former chair, paediatric professor Terence Stephenson, now chair of the British General Medical Council.
The content is UK-focused, but has relevance for doctors, patients and the practice of medicine the world over, including South Africa and its faltering National Health Insurance.
At its heart, Choosing Wisely is about stopping overzealous doctors in their tracks – doctors who overtreat patients, send them for screening they don’t need, overdiagnose and overprescribe drugs, surgery and other treatment regimens that don’t benefit much, if at all, and who keep patients alive when their bodies and minds are screaming to be allowed to “slip this mortal coil”.
It’s not just from doctors who can’t resist the temptation to play God. In a worst-case scenario, it’s doctors following the dictates of the god, Mammon, and making the most money possible out of treating patients.
I like to think that’s exception rather than the rule.
In best-case scenarios, it’s from doctors rushing in where even angels fear to tread, in their God-like quest to save lives and keep death at bay.
The world over, doctors overdiagnose and overtreat patients for diseases that may never cause much disturbance, never mind untimely death. They contribute to skyrocketing medical costs along the way.
That makes the BMJ analysis a much-needed injection of life-giving blood into modern medicine, and the authors just the ones to dispense it.
The analysis begins with an historical perspective that makes sobering reading on its own. The authors make the very salient point that the idea of doctors doing medical procedures that do more harm than good is “as old as medicine itself”.
By way of example, they cite Mesopotamian King Hammurabi who proclaimed a law “threatening overzealous surgeons with the loss of a hand or an eye” 3800 years ago.
A more recent example comes in 1915 cartoon by pioneering Boston surgeon Ernest Codman in which he mocked his colleague’s indifference to the harm they wrought on patients and posed the question: “I wonder if clinical truth is incompatible with medical science? Could my clinical professors make a living without humbug?”
That was at the height of what the BMJ authors call “a surgical vogue for prophylactic appendicectomy” – presumably much like the prophylactic mastectomy, oophorectomy and hysterectomy Hollywood actress Angelina Jolie has undergone over the past year.
It’s hard not to get the feeling that little has changed in the intervening years; if anything things have got a whole lot worse.
“Diagnosis drives treatment,” say the authors in the BMJ, and the tendency to overdiagnose and overtreat is growing stronger.
They define overdiagnosis as when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis”. By overtreatment they mean treatment of these overdiagnosed conditions, encompassing treatment with “ minimal evidence of benefit”, or that is “ excessive (in complexity, duration, or cost) relative to alternative accepted standards”.
The authors say that hasn’t always been the case in Britain. Even before the introduction of the country’s National Health Service (NHS), they say the British medical tradition was characterised by “late adoption and cautious use of new medicines, procedures, and technologies”.
— Reid Jenner (@TrueDiagnosis) May 3, 2015
In recent years, however, they say the UK has exhibited disturbing patterns of variation in use of medical and surgical interventions similar to the US, “though less extreme in absolute terms”.
The National Institute for Health and Care Excellence (NICE) set up in 1999 was in part meant to address “unwarranted variations in clinical practice and has identified over 800 clinical interventions for potential disinvestment”, the authors say. This hasn’t been enough to stop doctors from performing “ familiar or ingrained” practices.
Clearly, a prescription is required for “a different approach to that for introducing new treatments”.
The NHS has good systems for evidence appraisal and health technology assessment, but “better and simpler tools are needed to facilitate informed discussion in clinical settings”, the authors say.
“Without such robust and easily shared decision aids, systematically updated without bias, patients may be swayed by potential exaggerated claims in the media when new drugs or procedures are introduced.”
In adopting the initiative, the Academy of Royal Medical Colleges intends tackling underlying causes of overtreatment that include a culture of “more is better”, and the onus it places on doctors to “do something” at each consultation that has bred “unbalanced decision making”.
Just one effect is patients being offered what the authors call “low-hanging fruit”, including treatments with “minor benefit and minimal evidence despite the potential for substantial harm and expense”.
Such a culture “threatens the sustainability of high quality healthcare and stems from defensive medicine, patient pressures, biased reporting in medical journals, commercial conflicts of interest, and a lack of understanding of health statistics and risk”, the authors say. The Choosing Wisely initiative will also look at incentives to limit doctors’ activity.
I have treated 40,000 patients, and I have seen medicine change from a compassion-based profession into a corporate-greed driven industry.
— Gavin Preston, M.D. (@GavinPrestonMD) May 24, 2014
In this regard, NICE has produced guidelines for quality measures in both primary and secondary health that should not be written in medical stone. The authors say that decisions “need to be made with reference to individual patient circumstances, the wishes of the patient, clinical expertise, and available resources”.
Another problem the authors have identified is doctors’ “health illiteracy”, which is well-documented, especially around understanding research data.
Doctors need training in managing unrealistic expectations of patients, say the authors. Doctors also need to avoid misleading patients unintentionally by communicating relative instead of absolute risk or numbers needed to treat.
The analysis quotes Gerd Gigerenzer, director of Harding Centre for Risk Literacy in Berlin, in a summary in 2009: “It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks, to protect patients against unnecessary anxiety and manipulation.”
That’s the problem, which is daunting enough in size and scope, but what about solutions?
The authors issue a clarion call to action and say next steps should include different payment incentives for doctors and hospitals, and that:
- Doctors should provide patients with resources that increase understanding about potential harms of interventions, and help them to accept that doing nothing can often be the best approach.
- Patients should feel free to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler, safer options? What if I do nothing?”
- Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication. Students should be taught about overuse of tests and interventions. Organisations responsible for postgraduate and continuing medical education should ensure that practising doctors receive the same education.
In essence, Malhotra says, the analysis marks the time to “truly wind back the harms of too much medicine”.
- Main image credit: Truthout.org / Modern Furniture / CC BY
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