Re: Too much medicine; too little care
Too much medicine, too little care – editorial 6th July 2013
Professor Glasziou and his colleagues rightly suggest that investigation should be selective and targeted, yet it feels as though we are increasingly employing a scattergun approach to investigations across all fields. Whilst ‘overdiagnosis’ is currectly identified as problematic, surely this is a direct consequence of over 'investigation'. From serial CRPs, to myeloma screens through to full body scans our approach to the patient is increasingly weighted towards, if not reliant upon investigation, while the value of a thorough history and the art of clinical examination is increasingly being neglected. If this is indeed the case nationwide, (as is our belief), then some timely reflection is needed to establish why this is happening. Our own reflections and discussions with colleagues have raised three potential contributing factors;
Problem based learning is now integrated in most medical schools and with it comes a change in mindset and indeed the medical practice of junior and future colleagues. Issues have been raised to this effect by educationalists and a major concern is that patients are being seen as ‘presenting complaints’ and managed with a formulaic work-up. The corollary of all of this is ‘over-investigating’, over-diagnosing (and over spending).1
Secondly the climate of litigation has made clinicians increasingly fall back on unnecessary investigation and is impacting on our practice habits.2 Defensive medicine coupled with all-encompassing protocols drive up the investigation list in any given casualty department, acute medical unit, hospital ward or general practice.
Finally we witness how the European work time directives have affected junior doctor working patterns and continuity of care is often compromised. Patients on an acute ward may well see different doctors every day, who are then more likely to order a battery of tests as a fire-fighting mentality ensues. An interesting study demonstrates how this lack of continuity of care translates into doctors ordering investigations on patients they have never seen, (let alone considered the merit of the ordered investigation).3
There are of course other factors to consider and at greater length, but we feel that there is a trend that needs to be addressed; our investigating patterns are becoming robotic rather than considered and the care we provide often exhaustive rather than holistic. The ramifications of this will, we expect, continue to be highlighted in your current series on unnecessary care.
Department of Medicine for the Elderly
Dr Samad Samadian, Consultant Physician,
Dr A Farhat, GPST2
St Helier Hospital, Wrythe Lane, Carshalton, SM5 1AA
1. Paul A. Kirschner , John Sweller & Richard E. Clark (2006): Why Minimal Guidance During Instruction Does Not Work: An Analysis of the Failure of Constructivist, Discovery, Problem-Based, Experiential, and Inquiry-Based Teaching,Educational Psychologist, 41:2, 75-86
2. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609–17.
3. Bosanquet D, Cho J, Williams N, Gower D, Thomas KG, Lewis M. Requesting radiological investigations - do junior doctors know their patients? A cross-sectional survey. JRSM Short Rep. 2013 Jan;4(1):3.
Competing interests: No competing interests