A system reset for the campaign against too much medicine

The current burden on health systems is undoubtedly worsened by overdiagnosis and overtreatment. The BMJ highlighted the dangers of too much medicine in a theme issue in 2002 (https://www.bmj.com/content/324/7342). Drawing on Ivan Illich’s argument that the “medical establishment has become a major threat to health,”1 Ray Moynihan and Richard Smith, in an editorial in the theme issue (doi:10.1136/bmj.324.7342.859), explained “how life’s normal processes can be medicalised.”2 Importantly, too much medicine was, even then, a topic that mattered to our readers, since they voted for us to commission the theme issue. In 2015 a further editorial (doi:10.1136/bmj.h1163) launched our Too Much Medicine campaign (https://www.bmj.com/too-much-medicine) and our role in the Preventing Overdiagnosis conferences (https://www.preventingoverdiagnosis.net).3

Evidence of the damaging effect of overdiagnosis and overtreatment (doi:10.1136/bmj.k2820) continues to grow.4 It includes the cost to health services, workload pressure on staff, and harm to patients and the planet (doi:10.1136/bmj.n2407).5 This week we highlight how menopause, a natural event shaped by cultural and social attitudes, is medicalised (10.1136/bmj-2021-069369).6 Although the benefits of hormone replacement therapy, for example, are well researched (doi:10.1136/bmj.o1425),7 the risk-benefit calculus does not favour treatment for many women (doi:10.1136/bmj.o1389).8

Overdiagnosis is official; it is now recognised as a medical subject heading (MeSH) by the US National Library of Medicine (doi:10.1136/bmj.n2854).9 Yet, the forward march of “industrialised medicine” is relentless. The reasons are complex, but money is the primary driver. “Selling sickness” is a profitable business, and marketing disease exploits the fears and emotions of patients. Politics plays a part, because new treatments and promises of high tech interventions are attractive to voters. Health professionals are drawn in too, by their desire to do everything possible for the patient in front of them (doi:10.1136/bmj.o1204; doi:10.1136/bmj.o1415).1011 The picture is confused by some diseases and populations being underdiagnosed and undertreated. All this is amplified and complicated by the covid pandemic.

Too much medicine, a concept much more than 20 years in the making, may seem like a boxer on the ropes waiting for a knockout blow by the industries that sell sickness. That knockout blow won’t come. It won’t come because of the strong evidence we already have of the harms caused by overdiagnosis and overtreatment. It won’t come because the madness of rising demand on health services, of “low value healthcare,” must stop, because health systems everywhere are on the brink of collapse. It won’t come because the financial interests that drive too much medicine will be increasingly exposed as societies continue to open up. It won’t come because there are enough committed clinicians, policy makers, and patients, armed with evidence and solutions, to keep fighting, as I saw at the latest Preventing Overdiagnosis Conference in Calgary last week.

But some things need to change. Shannon Brownlee and Deborah Korenstein (doi:10.1136/bmj.n117) asked whether we would “stop overusing low value healthcare if we knew how often it hurts patients?”12 A focus on the harms to patients of overdiagnosis and overtreatment would make a more powerful argument than a focus on costs. This requires the science of harms to be better considered in research design, in health systems surveillance, in clinical education, in decision support systems, and by the media. The BMJ might play its part further by introducing a new section in research abstracts that obliges authors to explain whether they considered harms and what they found.

A second area of change would be to embrace the evidence from observational and real world data and to optimise data to better inform clinicians and policy makers about harms, without diluting the importance and centrality of well designed randomised controlled trials. Above all, the campaign against too much medicine needs a system reset to move from rhetoric and scattered evidence to actionable evidence and measurable impact.