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Doctors campaign against ‘too much medicine’

Pressure to ‘do something’ at each consultation has bred unbalanced decision making

Louise Prime

Wednesday, 13 May 2015

The culture of ‘more is better’, in which doctors feel the onus is always on them to ‘do something’ at each consultation, has bred unbalanced decision making and led to patients sometimes being offered treatments for which there is only minimal evidence and that have only minor benefit, despite the potential for substantial harm and expense, doctors’ leaders said this morning.

The Academy of Royal Medical Colleges, in partnership with specialty organisations including the BMJ, today announced the UK launch of the Choosing Wisely programme. This is an initiative recently developed in the US and Canada, and already widely adopted, to help overcome the health problems caused by overdiagnosis and overtreatment – including direct harms from unnecessary treatment, and increased patient anxiety resulting from diagnosis of conditions that will never cause symptoms or death – as well as the resulting waste of resources.

Cardiologist Dr Aseem Malhotra, president of the Academy, and colleagues, wrote in their Analysis in this morning’s BMJ: “The [current] system has no incentive to restrict doctors’ activity; the NHS in England has a system of payment by results, which in reality is often a payment by activity and encourages providers to do more both in primary and secondary care. General practice is increasingly pressured to focus less on open dialogue with patients about treatment options and more on fulfilling the demands of the Quality and Outcomes Framework (QOF, a pay for performance instrument) and adhering to local commissioning decisions.”

They also cited evidence of many doctors’ own misunderstanding of statistics, which often leads to a belief that screening is more beneficial than it actually is; and, in some cases, to no acknowledgment of its potential harms. Furthermore, they said, patients can be unintentionally misled over the risks and benefits of treatment because of confusion between relative and absolute risks, and ‘numbers needed to treat’.

They explained the project’s aims, and why they believe that the best approach to care can often be simply doing nothing. They said participating organisations will be asked to identify five tests or procedures commonly used in their field, that are of questionable value and whose risks and benefits should be discussed with patients before using them. These will be compiled into lists showing the ‘top five’ interventions for each specialty that should not be used routinely or at all.
They suggested that, to ensure the development of a Choosing Wisely culture in clinical practice:

·         Doctors should provide patients with resources that increase their understanding about potential harms of interventions and help them accept that doing nothing can often be the best approach

·         Patients should be encouraged to ask questions such as, “Do I really need this test or procedure? What are the risks? Are there simpler safer options? What happens if I do nothing?”

·         Medical schools should ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication. Students should be taught about overuse of tests and interventions. Organisations responsible for postgraduate and continuing medical education should ensure that practising doctors receive the same education

·         Commissioners should consider a different payment incentive for doctors and hospitals

They concluded: “It is time for action to translate the evidence into clinical practice and truly wind back the harms of too much medicine.”

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