Intended for healthcare professionals

Rapid response to:

Editor's Choice

How much medicine is too much?

BMJ 2019; 364 doi: (Published 28 February 2019) Cite this as: BMJ 2019;364:l902

Rapid Response:

Re: How much medicine is too much? Symptoms matter

I applaud BMJs contributions “to pull back the harms and waste of medical excess” as well as Dr. Godlee’s caution. I am struck, however, that the caution applies to a fundamentally different category of medical care.

The listed contributions highlighting too much medicine – routine monitoring in hospital, statins for all patients over age 75 and whole genome sequencing for healthy people – all fall in the category of anticipatory medicine. There is no clinical evident problem being addressed here, instead these are efforts to detect and avoid events that might happen in the future.

The caution, on the other hand, applies to a clinically evident problem – urinary tract infection – an event that is happening now.

The difference is symptoms. Symptoms matter. In symptom-driven medicine, patients are asking for our help; in anticipatory medicine, they are being told they need our help. Symptomatic individuals are more likely to suffer adverse outcomes (such as sepsis and death in the UTI cohort). Plus, the presence of symptoms means there is room to get better. It’s hard to make an asymptomatic person better.

Symptoms change the balance of medical benefits and harms. They make benefits more possible, the harms more acceptable. Of course symptomatic patients can suffer from too much medicine, but they can also suffer from too little. That’s why caution is called for.

H. Gilbert Welch MD, MPH
Thetford, Vermont

Competing interests: No competing interests

07 March 2019
H Gilbert Welch
General Internist
Thetford, Vermont USA