Monday, August 10, 2015

We're overdosing on medicine – it's time to embrace life's uncertainty

The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.
But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.

We’re all ill now

A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.
Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.
Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.
The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.  Have we set the threshold for illness and/or disease too low?


The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.
But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.

We’re all ill now

A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.
Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.
Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.
The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.
The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are often being paid directly by the companies that stand to benefit from turning millions more people into patients.

Fundamental shifts in thinking

Indeed, intolerance of uncertainty has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals.
More broadly, uncertainty is the basis of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.
No matter how much the marketers of medicines try to make us feel broken by the
mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review.


Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine.
But, there are many positive signs of change within medicine. The Choosing Wisely campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine.
A new approach called shared decision making is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called quaternary prevention is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.

Quaternary prevention is a group of measures taken to prevent, decrease and/or alleviate the harm caused by health activities. Health activities not only generally produce benefits, but also harm. That is to say, although medical intervention is mainly favourable, there is a dynamic balance that requires continuous assessment of the clinical situation as naturally only those health activities that achieve more benefit than harm at the end are justified. Quaternary prevention is the avoidance of unnecessary medical activity, such as "check-ups". In another example, quaternary prevention is the recommendation of preventive measures of proven efficacy. As regards diagnosis, quaternary prevention is, for example, the avoidance of screening without foundation, such as in prostate cancer. The appropriate use of antibiotics in upper respiratory tract infections serves as an example of quaternary prevention in the field of treatment. Another example is the application of the correct rehabilitation techniques in non-specific low back pain, such as swimming and maintaining an active life as much as possible. Not to forget other important "non-classic" aspects in the elderly, such as to limit the harm that can be caused by physical movement restriction devices. These and other examples in daily practice are considered in this article to encourage the continual assessment of quaternary prevention, the classic primum non nocere "first, do no harm".



We're overdosing on medicine – it's time to embrace life's uncertainty
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