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Editor's Choice

How much medicine is too much?

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l902 (Published 28 February 2019) Cite this as: BMJ 2019;364:l902
  1. Fiona Godlee
  1. The BMJ
  1. fgodlee{at}bmj.com
  2. Follow Fiona on Twitter @fgodlee

The BMJ’s long running Too Much Medicine campaign (bmj.com/too-much-medicine) continues our efforts to pull back the harms and waste of medical excess in all its forms. This week brings several contributions and also a necessary caution.

Abraar Karan targets excessive testing of patients in hospital (doi:10.1136/bmj.l841). Default options for regular checking of blood pressure, oxygenation, heart rhythm, and electrolyte balance can mean patients get no rest and suffer unnecessary discomfort, not to mention the extra work for the nursing and phlebotomy teams. Doctors should question what they ask for, he says, rather than just ticking the usual boxes. “Much of this comes down to the fact that doctors are not paying for the tests, are not the ones actually doing them, and are not the ones being stuck by needles.”

Next comes our columnist Rammya Mathew, who questions the latest headlines promoting statins for all patients over 75 (doi:10.1136/bmj.l807). Risk factors accumulate with age, of course, but trying to mitigate these risks with more and more drugs doesn’t seem like the right approach, she says.

Meanwhile, we have to contend with our politicians’ personal enthusiasms. England’s health secretary has proposed whole genome sequencing for healthy people, offering them a personalised account of their genetic risk for various diseases. This will no doubt prove popular with some voters, but it’s a recipe for overdiagnosis and overtreatment, says Christopher Semsarian (doi:10.1136/bmj.l789). A whole genome sequence can identify up to 12 clinically actionable DNA variants, he says, but we can’t accurately predict when or if a person will develop the associated disease. “Every healthy person who undergoes whole genome sequencing will effectively become a patient, requiring further clinical investigation and follow up.” Think again, Mr Hancock.

Finally, what more can doctors do to reduce unnecessary use of antibiotics? A lot has already been achieved, says Alastair Hay (doi:10.1136/bmj.l780), especially in primary care, where 80% of all antibiotic prescriptions are initiated. GPs in England have cut prescriptions by 13% in the past five years without increasing serious complications, including sepsis.

Shorter antibiotic courses will help. Koen Pouwels and colleagues conclude that GPs could cut 14 antibiotic days for every 10 prescriptions simply by following the new guidance (doi:10.1136/bmj.l440). But, and here is the note of caution, delay in prescribing antibiotics for urinary tract infections may contribute to higher death rates. This is the conclusion reached by Myriam Gharbi and colleagues, who emphasise the need for early initiation of treatment, especially in men, older adults, and people from socially deprived areas (doi:10.1136/bmj.l525).

When it comes to too much medicine, individual judgment will always be needed.

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