IN an unprecedented intervention, The Academy of Medical Royal Colleges, which represents all 21 medical royal colleges in the UK, has said that too many people in the UK are being “forced” into treatments and investigations that can do them more harm than good.
The reason for this, they say, is because of GPs increasing reliance for income on fulfilling the requirements of the “Quality and Outcome Framework” which pays GPs for performance. How does that work in practice?
GPs’ pay is linked to the prescription of drugs such as statins to protect against heart disease, and their level of participation in screening programmes for diseases such as cancer and diabetes. At the same time, hospitals receive money for each patient they treat with set fees for each operation and test they perform.
On a personal level, this dilemma was brought home to me on a recent trip to the GP when, being a male of a certain age, I thought I ought to enquire about the need or otherwise to have my prostate checked out with a PSA screening test.
Fortunately, the doctor I saw was “on the ball” (no pun intended) and she actually printed out a 10-page document of the latest thinking on PSA screening entitled something like “Doctors can improve the health of their male patients by advising against having a routine PSA screening test”.
The facts behind this headline are that having such screening has been shown to save the life of just one person in a thousand from death by prostate cancer.
On the other side, there are many others whose lives have been severely compromised through the battery of follow-up investigations needed (involving such things as invasive prostate biopsy) to “weed out” the false positives. And at times through the aggressive treatment of small areas of cancerous tissue that in all likelihood would never have progressed to cause clinical signs during the patient’s lifetime.
So, just because we can do it, doesn’t mean to say that we should.
Another example is the current use of antidepressants. Professor Peter Gotzsche, director of a research centre in Denmark, has suggested that millions of people should stop taking antidepressants as their long-term risks greatly outweighed their potential benefits. He went as far as to say that the administration of such drugs was responsible for more than half a million deaths of pensioners in the Western world each year, in part due to the increased risk of suicide in those groups taking the drugs.
Whilst this is probably an oversimplification of the issues involved, there seems little doubt that many people are shovelling medications down their throats, often at the behest of their doctors, for which there is little evidence of benefit and frequently quite the reverse.
In order to try to tackle this problem, the Royal Colleges are to start a campaign called “Choosing Wisely”. The initiative will call on all medical specialities to come up with a list of common medical practices which should be stopped because they do more harm than good.
The main purpose of the initiative is to encourage doctors to discuss with their patients the “value” of any treatment. What are the real benefits and what are the potential harms, so that the patient can make an informed choice about what, after all, is their own health and life.
The problem with such an approach is that some people don’t want to have to make a choice, preferring to put a kind of blind trust in the man or woman sat the other side of the consultation room. Or perhaps they lack the scientific and mathematical knowledge needed to make a genuinely informed decision.
However, for those who do want a say in what happens to them, it seems an eminently sensible approach as we strive for personalised medicine. It might, though, involve considerably longer periods of time in discussion on a oneto-one basis than has traditionally been on offer.
From a purely practical viewpoint, for the Choosing Wisely scheme to be a success there will need to be a change in the way that both GP practices and hospitals earn their money.
It is human nature to err towards the advice that will bring greatest benefit to the adviser and so incentives that encourage tests and treatments that the evidence suggests do not give overall benefits to the patient need to be removed.
This problem of over-treatment and over-investigation is not exclusive to the medical profession. One obvious example that springs to mind is the recommendation from various sources that companion dogs should be wormed at least every three months.
What is the evidence to support this? If the same dogs are also part of a routine flea control programme (which again one could question, especially when frequently using what are essentially systemic toxins), and are being fed on processed food, what are the real chances that they will ever become infected with tapeworms?
And yet we enthusiastically encourage owners to give them praziquantel every three months. Sure, it brings in a nice steady income but is it really in the best interests of the dog from its health point of view, or the client’s from their finances standpoint?
If the RCVS is promoting an evidenced-based approach to everything we do and recommend, is this not a great starting point for reviewing the data? After all, if doctors recommended treating everyone in Britain for head lice or helminths every three months, they would be ridiculed, wouldn’t they?
Likewise, I suspect there are tens of thousands of animals out there on repeat prescriptions of all manner of drugs for which there is very little, if any, evidence that they require them.
Sometimes I think it is because no one dares suggest stopping them for fear that the animal will take a “turn for the worse” and the distraught client will blame the foolish vet who suggested that Fluffy could probably manage without those little white pills she’d been taking for the last five years. And when it comes to the overinvestigation and treatment of animals, particularly geriatric ones, well just don’t get me started.
What I’m saying, I suppose, is that in light of what the medics have currently concluded about the over-treatment of people and the need to do something about it, we should perhaps take a step back and examine our own practices.
Evidence-based medicine is not a catch-phrase; rather, it is something that should be at the forefront of all our decision-making, even if that might mean the bottom line doesn’t look quite as good as we had hoped.
