Letters Harmful medical overuse

Systemic reforms are needed to reduce harmful medical overuse

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4711 (Published 22 July 2014) Cite this as: BMJ 2014;349:g4711
  1. Joshua Freeman, physician1
  1. 1University of Kansas Department of Family Medicine, Kansas City, KS 66160, USA
  1. jfreeman{at}kumc.edu

The Choosing Wisely campaign is an excellent step forward in getting physicians to think about what they are doing, and to follow the evidence.1 That these lists of recommendations are generated by the physicians’ specialty societies likely increases their effectiveness.

Most of the recommendations, however, are fairly specific to individual patients, tepid, and not system changing. Widespread adoption of some of the recommendations might have a great impact. Two such recommendations are waiting for the use of imaging for low back pain, and the American Society of Clinical Oncology’s first recommendation, which, although long with extensive modifiers, says “don’t use treatments that don’t work.”2 It is telling that many recommendations do not dramatically affect income. The “low back pain” recommendation from the American Academy of Family Physicians3—which has made 15 recommendations—is not mentioned by the American College of Radiology4 or the American Academy of Orthopaedic Surgeons,5 each of which has limited its recommendations to five.

More important than recommendations would be systemic reforms. These could include changing the way physicians are reimbursed—for maintaining or improving health, not “doing things”—and creating greater equity between payment for procedures and cognitive care, especially listening to and talking with patients. Other changes could ensure that everyone had financial and geographic access to care, and that this was equitably distributed on the basis of medical need. Those with fewer resources—or needing less profitable care—would not get less than they need, and those with more resources—or being considered for care that is more profitable—do not get unnecessary and potentially dangerous interventions.

It would be wonderful to see our medical organisations take the lead in these areas, as well as challenging some of the inappropriate interventions that make their members large amounts of money.


Cite this as: BMJ 2014;349:g4711


  • Competing interests: None declared.


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