Medical School interview course - Article 2

Doctors to withhold treatments in campaign against 'too much medicine'

Doctors are to stop giving patients scores of tests and treatments, in an unprecedented crackdown on the “over-medicalisation” of illness.

In a move that has roused fears that it will lead to the widespread rationing of NHS care, the Academy of Medical Royal Colleges is seeking to ensure that patients no longer undergo treatment that is unlikely to work, may harm them and wastes valuable resources. It wants to bring an end to a culture of “too much medicine” in which “more is better” and doctors feel compelled to always “do something”, often because they feel under pressure from the patient, even though they know that the treatment recommended will probably not work. Many patients with asthma, prostate and thyroid cancers, and chronic kidney disease already undergo “unnecessary care” because they are “over-diagnosed” and thus “over-treated”, the academy claims.

In a major change to patients’ relationships with their doctors, doctors must try to persuade the sick to stop expecting to automatically receive some form of medical intervention, such as drugs or surgery. It wants doctors to start talking honestly to patients about the benefit or potential lack of benefit from a certain procedure and the possibility that some treatments can involve risk, and about alternative ways of handling their illness.

In an article in the BMJ, a group of senior doctors said: “These new conversations will rebalance discussions about the risks and benefits of tests and interventions, such that doctors and patients will be supported to acknowledge that a minor potential benefit may not outweigh potential harm, the minimal evidence base, and substantial financial expense and therefore that, sometimes, doing nothing might be the favourable option” (British Medical Journal, Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. Volume 350: h2308)

Patients’ desire for treatment “has bred unbalanced decision-making. This has resulted in patients sometimes being offered treatments that have only minor benefit and minimal evidence, despite the potential for substantial harm and expense”, write the doctors. They warn that the NHS will not be able to cope with growing demand for healthcare unless over-treatment is banished.

The NHS’s “tariff” system of paying hospitals for treatment incentivises them to undertake medical activity, as does the Quality Outcomes Framework system under which GPs are rewarded. “Defensive medicine, patient pressures, biased reporting in medical journals and a lack of understanding of health statistics and risk” has also contributed to some treatments being performed regularly, despite a lack of robust evidence showing they work, they add. The Academy has decided to introduce a policy called Choosing Wisely, which is already used in other countries. It aims to get doctors to “stop using various interventions that are not supported by evidence, free from harm, and truly necessary”.

The Patients Association criticised the plan. “The concern is that this is the start of the road to widespread rationing of investigations and treatments.” They acknowledge that the NHS has to balance the books, but that should not be at the expense of treating patients appropriately. The Academy notes that the “whole point of Choosing Wisely is to encourage doctors to have conversations with their patients and about the value of a treatment. It’s not, and never will be, about refusing treatment or in any way jeopardising safety.”

Prof Maureen Baker, chair of the Royal College of GPs, said: “If there is evidence to show that a particular intervention might be of little benefit to a patient, it is good practice that alternatives are explored. For example, mindfulness and talking therapies have been shown to have positive effects in some patients with recurring depression and anxiety, as opposed to taking antidepressants. “However, family doctors are often under considerable pressure to prescribe, or take some form of action, as a result of a patient consultation, so it is important that we work together to make people realise that drug or surgical treatment isn’t always the best way forward.”