Intended for healthcare professionals

Feature Shared Decision Making

Can doctors reduce harmful medical overuse worldwide?

BMJ 2014; 349 doi: (Published 03 July 2014) Cite this as: BMJ 2014;349:g4289

Re: Can doctors reduce harmful medical overuse worldwide?

Considering the rampant enthusiasm of medical scientific societies to join the project Choosing Wisely and to define the five high-risk practices of inappropriateness, it seems appropriate to point out the main obstacles regarding the implementation of the project.

Problems on the demand side

Choosing Wisely project postulates the active involvement of patients (“alliance between doctors and citizen-patients”) to promote discussion with their clinicians about the need—or lack of it—to perform this or that test or treatment. Such "alliance" requires a "minimum" of clinical education on the patient’s side, in order to allow him (or her) to express preferences and to interact with physician about the utility or futility of the proposed diagnostic and /or therapeutic service. Today this condition cannot be easily met for the great majority of citizen-patients since between 70 and 85% of the population believe that medicine is an exact, or almost exact, science (1).

Consequently, the dominant physician-patient relationship will still remain "paternalistic", where the patient, not having technical knowledge, slavishly follows, without interaction, the suggestions of his (or her) doctor. Last, but not least, it is worth asking to what extent citizen-patients will perceive the "inappropriateness" of a medical service as an implicit rationing or the prelude to an explicit one.

Problems on the supply side

The project and the list of services at risk of inappropriateness should not become a "fig leaf" for the participating scientific societies. To avoid this major adverse event it seems mandatory for every society to implement (i) a monitoring system able to inform to what extent individual physicians will actively join the project and (ii) an evaluation program to follow the trend of the prevalence of practices - identified as being at high risk of inappropriateness - over time. This could be very easily implemented at a hospital level, while it would require both an investment and an innovative organizational framework at the territorial level.

In reporting the most common overused medical services in the US Choosing Wisely campaign it was highlighted that the majority of listed items targeted “imaging”(2). This fact points out the need to promote strong links and to build up consensual actions between radiologists and other medical professionals who prescribe radiological images.

It would be highly desirable to enhance the radiologists’ role in order to reduce the overuse of imaging tests prescribed by other medical specialists. Should radiologists play more a role of gatekeeper rather than of service provider (3)?

Last, but not least, more numerous and more courageous lists having a real impact on clinical practice should be developed and published.

Two other questions could be seriously taken into account to avoid the suggested “fig leaf” effect.

To what extent the propensity to avoid medical practices at a high risk of inappropriateness will be "honored" when that choice collides with economic individual or corporate incentives?

To what extent the fear of litigation (defensive medicine) will influence the appropriateness of prescribing behavior?

In conclusion, the Choosing Wisely project has aroused in many countries the enthusiasm of physicians and of other health professionals, as it is based on their responsibility in the appropriate use of resources.

We believe that the success of the project will, to a large extent, depend in particular on the sense of responsibility and on the ethical involvement of the participating physicians. The active involvement of patients, in fact, is likely to remain a mythical desire for the vast majority of them and for many years to come. However, the project can be a powerful tool for the community health education. In order for this to happen, though, it should be supported by an intense and intelligent communication campaign addressed to the general public and not only to elitist groups of consumers. In fact, the physician-patient encounter may not be sufficient to change habits and behaviors that already deeply entrenched (2).

(1) Domenighetti G., Grilli R., Liberati A. Promoting consumer's demand for evidence-based medicine. International Journal of Technology Assessment in Health Care 1998; 14: 97-105

(2) Morden NE, Colla CH, Sequist TD, Rosenthal MB. (2014). Choosing Wisely - The Politics and Economics of Labeling Low-Value Services. N Engl J Med 2014; DOI: 10.1056

(3) Saurabh Jha MB. From Imaging Gatekeeper to Service Provider - A Transatlantic Journey. N Engl J Med 2013; 369 (1): 5-7

Competing interests: No competing interests

10 July 2014
Gianfranco Domenighetti
Sandra Vernero MD and Antonio Bonaldi MD, Slow Medicine
University of Lugano and Slow Medicine
Via Praccio 5, 6900 Massagno CH