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Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine

BMJ 2015; 350 doi: (Published 12 May 2015) Cite this as: BMJ 2015;350:h2308
  1. A Malhotra, consultant clinical associate1,
  2. D Maughan, Royal College of Psychiatrists sustainability fellow 2,
  3. J Ansell, advanced trainee in general surgery3,
  4. R Lehman, senior research fellow4,
  5. A Henderson, chief executive 1,
  6. M Gray, director5,
  7. T Stephenson, former chair16,
  8. S Bailey, chair 1
  1. 1Academy of Medical Royal Colleges, London, UK
  2. 2Centre For Sustainable Healthcare, Oxford, UK
  3. 3Welsh Institute for Minimal Access Therapy, Cardiff Medicentre, Cardiff, UK
  4. 4Department of Primary Health Care, University Of Oxford, Oxford, UK
  5. 5Better Value Healthcare, Oxford, UK
  6. 6Institute of Child Health, London, UK
  1. Correspondence to: A Malhotra Aseem_malhotra{at}
  • Accepted 25 March 2015

A Malhotra and colleagues explain how and why a US initiative to get doctors to stop using interventions with no benefit is being brought to the UK

The idea that some medical procedures are unnecessary and can do more harm than good is as old as medicine itself. In Mesopotamia 38 centuries ago, Hammurabi proclaimed a law threatening overzealous surgeons with the loss of a hand or an eye. In 1915, at the height of a surgical vogue for prophylactic appendicectomy, Ernest Codman offended his Boston colleagues with a cartoon (figure) mocking their indifference to outcomes and asking, “I wonder if clinical truth is incompatible with medical science? Could my clinical professors make a living without humbug?” Looking at the rates of tonsillectomy in London boroughs in the 1930s, John Alison Glover discovered that they were entirely governed by the policy of school doctors and bore no relation to need or outcomes.1 John (Jack) Wennberg established the science of outcomes research when in 1973 he described patterns of gross variation in the use of medical and surgical procedures in the United States, which lacked any clinical rationale but was closely related to supply.2

“Back Bay golden goose ostrich” cartoon


Diagnosis drives treatment, and in recent years the term overdiagnosis has been used to describe various situations where diagnoses lead to unnecessary treatment, wasting resources while increasing patient anxiety. Overdiagnosis can be said to occur when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis.”3 Overtreatment includes treatment of these overdiagnosed conditions. It also encompasses treatment that has minimal evidence of benefit or is excessive (in complexity, duration, or cost) relative to alternative accepted standards.4 5 A recent report by the Academy of …

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