Unnecessary care: are doctors in denial and is profit driven healthcare to blame?
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6230 (Published 02 October 2012) Cite this as: BMJ 2012;345:e6230All rapid responses
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A colleague works for one of the many privately run Out-Of-Hours GP services. I
was shocked to hear that he recently received a phone call from the company to say that his
antibiotic prescribing rate was low compared with the other GPs’. Rather than praising his
practice, they asked him to increase his antibiotic prescribing in order to
meet patient expectations.
In my first six months of general practice I learnt how to reassure patients with minor illness,
explain how to self-care and encourage them to seek advice appropriately. It became clear
just how much time GPs spend promoting healthy lifestyles, aiming to improve quality of life
and prevent disease. Within a private service, I can see little incentive for health promotion.
Payment and profits depend on patient demand for the service, so why work to reduce
demand?
To me, this was a frightening example of pressure to change clinical practice, not with the
patient’s interest in mind, but to suit a business agenda. This leads me to wonder what other
pressures we will face as we start to interact more with private providers under the new
Health and Social Care Act. Are we going to be increasingly encouraged to shift our
focus away from health promotion? Will we see a decline in the conservative management of
minor illness, and a rise in the US style approach; one that is more invasive, treatment
intensive, and drug orientated?
As a GP trainee, I am acutely aware of the need to develop my skills in critical appraisal. I
believe that now, more than ever, we will need these skills to protect our
patients’ best interests. We must recognise conflicts of interest, and question the motives of
those who are not bound by our ethical code of conduct. Of course, GPs have been facing a
similar challenge for years from pharmaceutical company representatives. But I suspect
that influences on our decision-making will start coming from a wider variety of
sources, and may not be as obvious as a drug rep with a sales pitch.
Editorial note: Dr Oxley's colleague has confirmed her account of events
Competing interests: No competing interests
Whilst we found this article interesting, insightful and an eloquent voice of concern about the perils of overtreatment, we fear that many of your readership may feel that they can extrapolate some of the points to our National Health Service. One point in particular, regarding the rise of tonsillectomies in the USA is in stark contrast to our experience here in the UK.
The article referred ‘to an epidemic of questionable surgery (tonsillectomies alone increased by 74% from 1996 to 2006)’[1]. Health care professionals in the United Kingdom should be very clear that here ‘the questionable surgery’ of tonsillectomies rates have dropped by 38 % in England from 1991 -2011 (HES data)[2].
Within the UK we recognized the issue of excessive uncontrolled number of tonsillectomies several years ago, and this has been effectively addressed by the Scottish Intercollegiate Network (SIGN) guidelines Management of Sore throats and the Indications for Tonsillectomies [4, 5]. Indeed the criteria for tonsillectomy within the revised SIGN guidelines (versions 34 becoming 117) are even more stringent.
In addition to this, the recently created lists of operations deemed to be ‘procedures of limited clinical effectiveness or PoLCE’ include tonsillectomy. This cost savings drive within the NHS has been further enhanced by the austerity measures currently imposed within the UK despite the fact that there has been no evidence base for including tonsillectomy within this list. On the contrary, there has been serious concern that if too few tonsillectomies are done, then we will experience a rise in hospital admissions with severe tonsillar infection and the ensuing complications. A position statement in support of tonsillectomy was therefore published by ENT UK in 2009 [3].
Unlike our colleagues across the pond, the state of affairs here in the UK has possibly gone too far in the opposite direction with too few tonsillectomies being performed. Reducing the number of tonsillectomies may have late sequelae, with a rise in the number of peri-tonsillar abscesses and deep neck spaces infections. Our own investigations have shown that over the period of 1991-2011 in addition to the 38% drop in the number of tonsillectomies being performed, there has been a 355% (no decimal point!) increase of the number of admissions with acute tonsillitis and a 45% increase in the number of admissions with peri-tonsillar abscesses [2].
Too many tonsillectomies are no doubt harmful, exposing patients to unwarranted risks but too few have potentially detrimental consequences for both patients and the economics of the NHS. As Oscar Wilde once remarked ‘Everything in moderation, including moderation.’
References
1. Lenzer, J., Unnecessary care: are doctors in denial and is profit driven healthcare to blame? BMJ, 2012. 345: p. e6230.
2. HES, Hospital Episode Statistics, DoH, Editor 2012, HM London.
3. ENT-UK, Indications for Tonsillectomy: Position Paper ENT UK 2009, 2009, Royal College of Surgeons: London.
4. SIGN, Management of sore throat and indications for tonsillectomy. Scottish Intercollegiate Guideline Network Number 117 2010.
5. SIGN, Management of sore throat and indications for tonsillectomy. Scottish Intercollegiate Guideline Network Number 34, 1999.
Competing interests: Andrew Lau, Valerie Lund and Andrew Swift are members of ENT UK
The distribution, quantity and quality of health care are demonstrably a problem for health systems and payers, but particularly for society at large. There is a lack of a coherent conceptual frame-work in which to view the problem.
What is health? How should physicians enhance health?
Evolutionary medicine and systems medicine see human health as ’an evolved, complex system that strives to maintain homeostasis and promote individual survival and genetic reproduction’.[1]
Upstream knowledge including the fields of phylogeny, life history theory, genetics, biochemistry, and evolutionary medicine help us understand the complex nature of human development, aging and dying. Intra-system integrity of the person, their genome, their physical, social and environmental stresses and supports, and their epigenetic adaptation should be central to any conceptual framework to evaluate the value of health interventions. Similarly, this framework should encompass the health of populations including social and non-social determinants of health.
Funders and managers of health services see health episodes in terms of classifications and costs; and the information systems in place provide the basis for these judgments. However, information, ideas or evidence that inform particular knowledge systems are never ’innocent’, without tacit and explicit assumptions which may or may not best serve the individuality of personal health journeys.[2]
We, as physicians, need to have a clear notion of what promotes health at individual and population levels underpinning our activities, although details will continually change as new information emerges. We can, then, better participate in the debates about whether health is a public or private good, or a mix. The political economy of health care should be informed by clear notions of what is health and health promoting.
Medicine should serve society by advocating for and providing care in health enhancing systems, not seeking personal profit as a primary objective, nor working for organizations that have profit as their main objective. If profit motive, rather than just reward for work well done, is the primary rationale of physicians, we have lost our way and need to re-examine our selection, training, representative organizations and reward systems.
[1] Lewis S. Seeking a new biomedical model. How evolutionary biology may contribute. J Eval Clin Pract. 2009;15(4):745-8. Epub 2009/08/14.
[2] Martin CM. Making sense of polarities in health organizations for policy and leadership. J Eval Clin Pract. 2010;16(5):990-3. Epub 2010/09/18
Competing interests: No competing interests
Money is like blood, and poverty is like anemia. Anemia is physical and caused by weakness, malnutrition, infection, and bleeding. Poverty is fiscal and caused by bleakness, maldistribution, deception, and cheating. Anemia may need a transfusion from the blood bank, but poverty may need an infusion from the bloody bank.
Competing interests: No competing interests
I have always been perplexed by the dichotomy between evidence and profit. It doesn't seem to matter what the evidence supports the bottom line is does it make money. Obamacare is positioning hospitals to be the big winners and this is absolutely the most expensive (and wasteful) method of providing healthcare.
I am reminded of a quote attributed to William James: "No priesthood ever initiated its own reform."
Competing interests: No competing interests
Using brain-death criteria, the medical community can declare a person legally dead even if life support equipment keeps the body's metabolic processes working. However, putting an end to someone's life creates many ethical dilemmas.
Many patients perceive death as a natural part of life, or relief from pain, and they may express a wish to die quickly and painlessly. They often ask the treating physician and their family to be allowed to go home and die peacefully. However, the next of kin may want the patient to be actively treated and kept alive. The physician hopes that the patient will survive and resorts to technical means to keep the patient alive. Who should decide; the patient, the family or the physician?
The love and care of family and empathy of physicians compel them to proceed with the treatment. Continuation of treatment has no medical benefits except the prolongation of the biological span of life with total compromise on the quality of life. The dying person’s wish to die peacefully among his/her favorite home or place surrounded by an atmosphere of the person’s choice will make the last moments of life and journey to death peaceful and dignified.
But one must remember hope is the milestone of medical care. One cannot call care unnecessary or irrelevant in any context unless and until proven right.
Competing interests: No competing interests
Re: Unnecessary care: are doctors in denial and is profit driven healthcare to blame?
From Google dictionary "Care" is defined as:-
Noun: The provision of what is necessary for the health, welfare, maintenance, and protection of someone or something. Verb: Feel concern or interest; attach importance to something: "they don't care about human life".
There are two facts which we need to be aware of and hold in tension here. Firstly, that the language used by people in the medical profession (doctors, hospital managers etc) is different to that of the general public. Secondly, as medical professionals our words hold much weight and even power, and does much to encourage a patient or indeed discourage them.
Therefore, words as innocuous as 'care' need to be used with great care as it were. We need to reassure patients that if you come to see a doctor you will receive care. We will try to reduce unnecessary 'treatments and investigations' but we will certainly still care for you. You will be warm, be fed, be kept informed and be treated with dignity and respect.
I would go so far as to say that palliative care should remain termed as such and not be changed to "palliative medicine". It simply does not embrace the social workers, the chaplains, the volunteers and others who contribute greatly to the multidisciplinary nature of caring for people who have life-limiting illnesses.
Using the phrase 'Unnecessary care' in your title simply adds fuel to the fires of spin-doctors and sensationalist tabloids. Please, be mindful of the words you choose to use.
Competing interests: No competing interests