November 30th 2016, 08:18
It should be the golden rule of medicine (yet it’s never taught in medical school): first, do nothing. Instead, the fledgling medic is cast in the mould of the hero, ready and waiting to intervene at the drop of a blood-pressure reading.
To help him in his quest to restore health to all are the paraphernalia of the newest technologies, including computer-aided screening tests, scans and X-rays, and the latest breakthrough drugs.
The trouble is that much of it is either unnecessary, untested, unproven or ineffective—and, in some cases, all four.
A recent survey of more than 5,000 doctors discovered that 83 per cent admitted requesting a scan or prescribing a drug that they knew was unnecessary or useless. They often did so, they said, either out of fear of litigation—in other words, as long as the doctor is seen to be doing something, even if it’s useless or harmful, he’s in the clear—or because of demands by the patient. “You’re the doctor, do something.”
But it’s also to do with box-ticking, says Simon Stevens, head of the UK’s National Health Service (NHS). Doctors’ pay is, in part, linked to treatment targets, so the more they prescribe, the more they get paid.
The UK’s Academy of Medical Royal Colleges—which represents 22 royal medical colleges—has just released a list of 40 treatments that are routinely given, yet are useless or unnecessary. Controversially, perhaps, the list includes giving chemotherapy to patients with advanced cancer, but also includes ordering X-rays for lower-back pain, regular scans for terminally ill patients and routine checks for patients who have had ‘every-day’ surgery, such as a cataract procedure.
Prof Dame Sue Bailey, the AMRC’s chairman, said, “Patients should ask what would happen if I do nothing?”—a question that could just as reasonably be posed by the doctor. And the unspoken answer is invariably . . . nothing.1
This is just the start. The AMRC plans to come up with a list of 150 useless treatments before long, and that shouldn’t be a difficult task, either. The 2007 BMJ Clinical Evidence Handbook calculated that only 13 per cent of drugs and procedures are, without question, beneficial, while a further 23 per cent are likely to be so. That means just 36 per cent of all drugs, surgical procedures and other interventions will probably or certainly do you good.2
The initiative is an echo of the Choosing Wisely campaign that’s been running for a few years in the US. The campaign has brought together more than 70 groups, each representing a medical specialty, which listed the five most unnecessary or ineffective treatments in their field. They included prescribing antibiotics for sinusitis, ordering an MRI (magnetic resonance imaging) scan for back pain and requesting an exercise
stress test for someone with no signs of a
It’s all a terrible waste—of time, money and resources. Estimates by the American College of Physicians and the Institute of Medicine are that overtreatment—another word for the commissioning of unnecessary tests and procedures—represents an eye-watering $700 and $765 billion, respectively, which is about a third of the total health bill in the US every year.3 And some researchers suspect the true figure could be higher still.4
Just as in the UK, overtreatment is often driven by fear of litigation—which is an even bigger threat for doctors in America—and because patients ask for it. But it’s also because doctors just don’t know what is actually appropriate for their patients.
There’s another consequence of ordering up a panoply of pointless procedures that is not being talked about by healthcare professional groups: the patient. No procedure, test or drug comes without a potential side-effect or harm, which means that the patient runs a gauntlet of risk of something going wrong every time he is given any sort of treatment
The thought that someone could be harmed or suffer life-destroying effects from a procedure that wasn’t even necessary in the first place is sacrilegious and blasphemous in the face of medicine’s god, Hippocrates. He famously said: first, do no harm—which, despite what everyone thinks, is also not taught in medical school.
Perhaps it’s time that ‘first, do nothing’ is.