A month or so ago I wrote a piece about regarding the fact that in medicine, less can be more. It is certainly the case that some conventional medical approaches have downsides that outweigh any upside. Some are worth than useless. Modern medicine, with its learned personnel, sophisticated testing and machines that go bing, has this sheen of being brilliant and effective and all. Scratch a bit, though, and one soon realises that a lot of what we doctors do is quite ineffective and/or downright hazardous. See here and here for more about this.
So, I was interested to read a piece in this week’s BMJ penned by its associate editor, Dr Christopher Martyn . In this piece, Dr Martyn questions the commonly held notions that more medicine is generally better.
He first of all goes after testing, and the fact that doctors tend to over-order tests to ‘play it safe’. As Dr Martyn points out, “Investigations are too likely to throw up incidental findings irrelevant to the symptoms the patient is actually complaining about. At best, this is a waste of time. More often, it leads to yet more investigations, further clinic appointments, and avoidable anxiety. Although doctors know this, it doesn’t act as a deterrent. They remember the few occasions when a test paid off and forget the hundreds of times when it didn’t.”
There’s other reasons why, I think, doctors tend to over-investigate. While at medical school we are taught to do the bulk of out diagnosing on the basis of the ‘history’ (what the patient tells us or someone else tells us about the patient) and a physical examination, after which we order tests, ideally to confirm the diagnosis, in reality, doctors often don’t have the time to work this way. And some doctors, of course, don’t really like people all that much, and use tests as a substitute for good, old-fashioned human interaction.
The tendency to over-order tests and investigations is compounded, according to Dr Martyn, by the fact that here in the UK, patients are not paying out of their pockets. But of course, in a way they often are (through a variety of taxes). But as Dr Martyn quite rightly points out, this fact tends not to act as a constraint: “Doctors don’t decide not to order tests or not to prescribe treatments because they’re worried about the tax burden on people who aren’t their patients. And patients don’t turn them down because they’re concerned that they’re getting more than their fair share.”
Another factor that contributes to the overuse of medicine is the fact that what most doctors are able to offer falls short of patient expectations. Might treatment be more effective if given earlier in the course of the disease? So, now we start thinking about screening individuals and the “invention of conditions such as pre-diabetes and pre-hypertension.” (emphasis mine). Dr Martyn wonders “how many doctors involved in these enterprises have any understanding of how many people they need to screen and, of those who screen positive, how many they need to treat, to prevent one case of disease. When my own general practitioner measured my blood pressure recently, I gracelessly asked him about the number of middle age hypertensives that he would have to treat to avert one stroke or one acute myocardial infarction. He hadn’t the faintest idea.”
The thing that Dr Martyn does not common on, perhaps because it’s beyond the scope of the piece, that it is known that generally a lot of people have to be screen to save a single life. And also, screening can cause some individuals to end up having unnecessary, damaging, and sometimes life-shortening treatment. See here and here about some of these issues as they relate to screening for breast and prostate cancer.
At the end of his piece, Dr Martyn laments that “We’re now in the ludicrous position that it’s electoral suicide, even in a country on the verge of bankruptcy, for a political leader to make an argument that we’ve been spending too much for too little gain and that, if the budget for health care were cut and doctors did less, most people would be better off.”
If you want, you can read about Dr Martyn’s career path here. He started out as a neurologist, before movning out of clinical medicine and into research and medical journalism. I’m left wondering if Dr Martyn’s career progression reflects some deep realisation that much of what doctors do simply fails to have the positive impact the image of the profession suggests.
1. Martyn C. Why medicine is overweight. BMJ 2010;340:c2800