Too much medicine: the challenge of finding common ground

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MALCOLM WILLETT

Over the past few decades a “global, progressive, and activist health movement” has coalesced that broadly aims to “challenge the selling of sickness” and confront the problem of “too much medicine” in all its forms.1 2 There is consensus within this movement that far too often patients are injured by unnecessary or excessive medical care, and that too much medicine fuels waste and rising healthcare costs. The BMJ’s Too Much Medicine campaign (www.bmj.com/too-much-medicine) and this special theme issue aim to shed further light on the problem.

But what is too much medicine and who gets to decide? The phrase itself is a catchall term used to describe a variety of problems, including overdiagnosis, overtreatment, and medicalisation. It works well for advocacy, say Stacey Carter and colleagues in their article (doi:10.1136/bmj.h869), because it is broad and inclusive.3 More precise definitions, though, are needed for specific purposes. Those who wish to debate, conduct research, or make policy recommendations must clearly characterise the exact features of what they wish to discuss or study. They should also, say these authors, recognise the ethical considerations implicit in any definition. These include what types of benefit or harm should matter, and who should be the judge of this.

Our imprecise terminology may go some way to explaining the slow progress towards solutions. So too may the dearth of good research into interventions that might constrain medical excess. Evidence based interventions are needed as much in low resource settings as they are in high resource settings, as Ansah and colleagues make clear (doi:10.1136/bmj.h1019).4 In countries like Ghana, with poor access to reliable laboratory tests for malaria, the safest bet is to treat every person with a fever with antimalarials. Their study shows that this wasteful and harmful misuse can be reduced if rapid diagnostic tests are made easily available in shops.

In developed countries, meanwhile, mammography screening has come to epitomise the problem of too much medicine. As Barratt says, it transforms “well women into patients who are exposed to all the risks of cancer therapies” (doi:10.1136/bmj.h867).5 She traces the evolution of ideas about overdiagnosis of breast cancer and explores the next steps. “We know enough to begin,” she says. To start with, health professionals should present mammography to women as a choice with pros and cons, and it should not be seen as a marker of health service quality. She calls for better public and professional awareness of the risk of too much medicine.

But can we assume that a more knowledgeable public will put the brakes on? A recent trial showed that a decision aid with information about overdiagnosis did reduce enthusiasm for mammography, but the decrease was small.6 Van den Bruel and colleagues confirm that information alone is not enough (doi:10.1136/bmj.h980).7 Presented with the same information about harms and benefits of cancer screening, members of the UK public nonetheless reached a wide variety of conclusions. Some were unwilling to tolerate any amount of overdetection, even when potential benefits were large. Others were willing to accept overdetection in everyone who was screened. The authors concluded that some people would prefer to experience harm from cancer treatment rather than from cancer itself.

So although there is consensus that too much medicine is real and damaging, large uncertainties remain about where and how the lines between appropriate and inappropriate care should be drawn in any individual case. And to this we must add the growing doubts about the reliability and independence of the evidence base on which patients and their doctors rely.

As the articles in this issue make clear, too much medicine is not one problem but a collection of problems. Each is likely to require a distinct approach. The Preventing Overdiagnosis meeting later this year will provide another opportunity to explore these ideas further (www.preventingoverdiagnosis.net). As well as being against too much medicine we can begin to devise and champion evidence based alternatives, such as rapid diagnostic tests, watchful waiting, and delayed prescribing.8 9 In the meantime, perhaps we can agree that decisions about what constitutes “just right” medicine are best made not by experts or committees but by individual patients in true collaboration with their doctors, armed as far as possible with relevant, reliable, and independent information about benefits and harms.