Published 25 June 2009, doi:10.1136/bmj.b2561
Cite this as: BMJ 2009;338:b2561

Editor's Choice

Less medicine is more

It would be fair to say that the BMJ tends towards less rather than more medicine. We’ve published a lot over the years on the risks of overtreatment and the problems of medicalisation. It’s not a bad default to have in times of economic hardship, although I hope we also do our bit to highlight evidence of undertreatment where it exists. In a recent letter David Oliver warned that, although ageing should not be routinely medicalised, there is a risk of "socialising" treatable problems in older people such as incontinence and falls (BMJ 2009;338:b1200).

With that proviso, I’m drawn to several articles this week that champion the view that less is more, and in particular that if you give patients complete and unbiased information about the likely effects of an intervention they may well say no to it. Iona Heath sets us off on this tack, writing about her decision to turn down mammography screening (doi:). She thinks the evidence is pretty clear that the potential harms of overdiagnosis outweigh the potential benefits of an accurate early diagnosis. But she’s worried that her decision is based on information that her patients can’t easily find because the invitation leaflet doesn’t mention harms.

This criticism has already been levelled at mammography screening by Peter Gøtzsche and colleagues, first in 2006 (BMJ 2006;332:538-41) and, because no real changes were made to the UK’s leaflet, again earlier this year (BMJ 2009;338:b86, doi:). Heath’s words are sure to fuel the already heated debate seen in our rapid responses (www.bmj.com/cgi/eletters/338/jan27_2/b86). Nicholas Wald, Malcolm Law, and Stephen Duffy criticised Gøtzsche and colleagues for substantially underestimating the survival benefits of screening. Gøtzsche and co have replied in extensive detail and, nearly two months on, have not been challenged again. In private emails to the BMJ, advocates of the NHS breast screening programme have criticised us for not adequately presenting the facts in support of screening. We would welcome a balanced article on this subject. But for the moment what is being asked for is simply that women should be made aware of the potential for harm from overdiagnosis so they can make a more informed decision.

What about providing complete and unbiased information for patients with psychiatric conditions? Joanna Moncrieff and David Cohen think this can only be achieved by changing the way we explain how antidepressants and antipsychotics work (doi:). Rather than portraying them as acting on specific disease processes, as their names imply, it would be more accurate and helpful to explain to patients that these drugs act by inducing a range of altered mental states. The authors think this could shift the emphasis of treatment away from continuous disease control towards periodic symptom control, with the potential to minimise the harms of long term use.

Finally, although screening for abdominal aortic aneurysm seems to be effective and, for the moment in the UK, cost effective (doi:, doi:, doi:), routine monitoring of bone mineral density in postmenopausal women being started on bisphosphonates looks to be a waste of time (doi:, doi:).

Cite this as: BMJ 2009;338:b2561

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This article has been cited by other articles:

• Lewis, L S. (2009). Deciding on whether to screen. BMJ 339: b3041-b3041 [Full text]  
• Wald, N. J, Law, M. R, Duffy, S. W (2009). Breast screening saves lives. BMJ 339: b2922-b2922 [Full text]  

Rapid Responses:

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more or less

L Sam Lewis
bmj.com, 28 Jun 2009 [Full text]

Medicalisation

Rahul Shetty
bmj.com, 29 Jun 2009 [Full text]

Less means more: 100% QOF achievement may not be ideal

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