Editor's Choice US Editor’s Choice

More excess needed. Occasionally

2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8176 (Published 30 November 2012) Cite this as: 2012;345:e8176
  1. Edward Davies, US news and features editor
  1. edavies{at}bmj.com

Many of the difficulties in the US healthcare system revolve around excess. There is the caricatured excessive energy consumption of its patients, of course, but also the excess of the entire system.

Two weeks ago this column flagged up the excessive and increasing proportion of gross national product going toward healthcare across the country (www.bmj.com/content/345/bmj.e7127?ijkey=WvGIF8lkG3h11qi&keytype=ref). Two months ago we published an investigation into the excessive treatment of patients in America (www.bmj.com/content/345/bmj.e6230). And this week the theme resurfaced in our news pages as we reported a study from the New England Journal of Medicine which concluded that “screening mammography has resulted in the overdiagnosis of breast cancer in 1.3 million women in the United States in the past 30 years.” (www.bmj.com/content/345/bmj.e7910).

This week, however, we visit two areas where it could be argued that more must be done, not less.

The first comes in a personal view from Frank Davidoff, executive editor at the Institute for Healthcare Improvement in Connecticut. In his article he argues that “the current mechanisms for identifying promising hypotheses and selecting them for testing are haphazard, inefficient, and far from rational” (doi:10.1136/bmj.e7991). It would be over simplistic to say he is just calling for an increase in hypotheses, but there is a clear tenor that the status quo is, at least, not working.

Among those things he does call for is “funding creative work separately from implementation studies” and “as a matter of editorial policy, clinical journals must encourage publication of well founded studies that generate hypotheses.” His ideas will not win universal support but it is, I suppose, one hypothesis.

Our second article is a clinical review on generalized anxiety disorder (GAD) (www.bmj.com/content/345/bmj.e7500). The authors, from Boston, say that the problem is poorly diagnosed and poorly treated. “In a large study of patients and their primary care physicians, physicians correctly recognized and diagnosed GAD only 34% of the time,” they write.

This matters because there are effective treatments that can improve quality of life and reduce the risk of major depression. Patients with this disorder are often heavy users of primary care, so tackling underlying anxiety may reduce the burden on overstretched health services—and, as a result, it could cut that excessive spending mentioned above.


Cite this as: BMJ 2012;345:e8176