Too much medicine; too little care
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4247 (Published 02 July 2013) Cite this as: BMJ 2013;347:f4247All rapid responses
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The authors are correct about the harms of Too Much Medicine. A major factor in the developing crisis of capacity in British primary care is the huge expansion in risk factor modification treatment and lowering of diagnostic thresholds and treatment targets. We have sleepwalked our way into this, as someone, somewhere decided that interventions with an absolute risk reduction of one or two percent represented good medicine.
The needs to be a major shift in how we think and communicate – away from a traditional idea of “Diagnosis then Treatment”, and towards a model where we honestly recognize that we are dealing with an analogue range of biological variables and can only offer a number of choices (non-pharmacological and pharmacological) to our patients along with enough information for them decide what tests and treatment they would like.
For this to happen, primary care doctors need to have easy access to relevant evidence. At the moment we are driven by prescriptive, linear guidelines (mainly from NICE) which include no, or little, information about the real clinical benefits of interventions to individual patients. As has often been said - we need ARR and NNTs to use in combination with assessments of an individual’s background risk. We need to know about outcomes that matter, not surrogate end-points. We need to know what the quantitative risks of treatment side effects are . We need to think more about when to stop treatment and how to make judgements about lifelong treatment based on 5 year trial data.
I agree with Dr. Barraclough who has responded to this article with a call for guidelines to be written by generalists, for generalists. An idea for primary care organisations to consider.
Competing interests: No competing interests
We agree with Glasziou and colleagues that it is time to find ways to safely and fairly wind back the harms of too much medicine. Surprisingly, Japanese doctors and patients face much the same conundrum. While the Japanese health care system is correctly lauded as a model of cost containment while achieving better outcomes on many key health indicators than the U.S. and other developed nations, over the past decade there has been a tremendous increase in the use of unnecessary diagnostic tests in Japan driven by aggressive direct to consumer advertising. Based on data provided by the Japan Brain Dock Society (1) and the Japan PET Scan Net (2), there are currently about 220 screening centers with magnetic resonance imaging (MRI) brain scans and 200 cancer screening centers with positron emission tomography (PET) throughout the country. Healthy, asymptomatic people are urged to undergo MRI screening to detect possible asymptomatic stroke or unruptured aneurysms. PET screening is advocated to screen for asymptomatic occult cancers. Neither of these screening tests is supported by evidence and likely lead to harmful adverse effects by downstream invasive workups and unnecessary surgical procedures. Most of these screening centers are operated by hospitals, including university hospitals and academic medical centers. The tests are advertised directly to consumers and are profit making for these hospitals both from direct payment for the test itself and by leading to costly and usually unnecessary ‘self-referrals’ for work-up of the incidental findings. We hope that Japanese medical entities and physicians will withdraw from the unethical business of promoting unproven and potentially harmful screening tests.
Reference List
(1) The Japan Brain Dock Society: homepage accessed at http://jbds.jp/nintei_list.html (July 7, 2013)
(2) The Japan PET Scan Net: homepage accessed at http://www.pet-net.jp/pet_html/search.html (July 7, 2013)
Competing interests: No competing interests
The start of science was arguably Descartes’ formulation of systematic doubt. Yet today the sceptic sometimes seems underrepresented on expert committees.
Current guidance requires that I urgently refer every patient with a raised PSA(1) (that is 10% of men aged over 50(2)), pigmented lesions which score 3 on the 7 point score(1) (which is 50% of all pigmented lesions(3)), microscopic haematuria in someone over 50(1) (up to 16.1% of the population(4)), all patients with dysphagia(1) (present in 14% of those with GORD(5)), etc, etc. 10% of the population have CKD. 50% of women over 50 have “osteopenia”. Guidance advises that huge numbers should be treated for hypertension and hypercholesterolaemia.
Yet there is little recognition that studies are good at measuring the high level benefit to the few, but are poor at identifying the low level harm to the many(6). We have a measure of how many, once diagnosed, we need to treat to benefit (NNT), but we have relatively little idea of how many we harm, or of how much we harm them. We have no measure of how many we need to investigate to benefit (for PE for example), and we rarely discuss thresholds of absolute risk. If we refer patients at 11% absolute risk (as we do with cancer in the UK) we have a 50% chance of detecting disease after we investigate 6 people. At 1% risk, we investigate 69 before we get an evens chance of a diagnosis.
My wife and colleague Jenny du Toit had a powerful idea to reduce overmedicalisation. Exclude subspecialist expert authors from guidance committees. Insist instead on generalist authors, appropriately advised by expert subspecialists. The expert is rather rarely a therapeutic or diagnostic sceptic. The “SIF” (Single Issue Fanatic) sees their specialist condition everywhere. Research grants and recognition are proportional to the perceived importance of the condition. But their unmodified enthusiasm risks medicalising the world. Descartes had it right. The sceptic needs a voice.
Reference List
1. National Institute of Clinical Excellence. Referral guidelines for suspected cancer in adults and children. 2005. NICE.
Ref Type: Report
2. Alexander, F and et al. Prostate Cancer Risk Management Programme. 2002.
Ref Type: Pamphlet
3. Whited JD,.Grichnik JM. Does This Patient Have a Mole or a Melanoma? JAMA 1998;279:696-701.
4. Cohen R,.Brown R. Microscopic hematuria. N Engl J Med 2003;348:2330-8.
5. Kawashima,.et al. Prevalence of dysphagia among community dwelling elderly individuals as estimated using a questionaire for dysphagia screening. Dysphagia 2004;19:266-9.
6. Kent DM,.Hayward RA. Limitations of Applying Summary Results of Clinical Trials to Individual Patients: the need for risk stratification. Journal of the American Medical Association 2007;298:1209-13.
Competing interests: No competing interests
The problem of too much medicine and too little care most profoundly affects patients (and the health care system) at or near the end of life.
Patients remain at risk of receiving treatments they never would have wanted had full and informed consent been obtained, and physicians frequently offer and provide treatments that, even prospectively, can only pointlessly and painfully prolong the dying process.
Competing interests: No competing interests
Re: Too much medicine; too little care
It is notable that the editorial warns us of one red flag of "overdiagnosis" as "increasing incidence with same mortality". I see an exception in the overly aggressive screening and labeling for Type 2 Diabetes.
Recent mainstream media reports a claim of lowering of mortality of diabetics over the past 10+ years as discussed in "Diabetologia, the Journal of the European Association for the Study of Diabetes", from 90% to 51% (1). Very impressive if it were really because of our management strategies. But it is most likely a result of a "dilution" of the documented diabetic population, which previously were only made up of high risk "type 2" and type 1 diabetics. Increasing numbers of asymptomatic very low risk "type 2 diabetics" are now being labeled and recruited into the diabetic population making the overall prognosis better. It is a matter of increasing the denominator (diagnosed) and not decreasing the numerator (mortality). Other factors may come into play like overall improved quality of life and healthcare.
I hope type 2 diabetes is not missed as an "overdiagnosis" as it manages to pass one criteria while failing in all others.
reference
(1)http://www.cbc.ca/news/health/story/2013/06/20/diabetes-deaths.html
Competing interests: No competing interests