When doctors do harm
Its incidence of doctor-caused disease is unacceptably high worldwide, given that doctors are supposed to heal patients, not harm them. In the US it is the third leading cause of death.
It is the focus of a ground-breaking Choosing Wisely campaign launched in the UK by the Academy of Medical Royal Colleges. It aims to protect patients from the harm caused by “too much medicine”, and stop doctors from being life-takers instead of life-savers.
Choosing Wisely is an initiative developed in the US and Canada. It has become an international campaign, as other countries, including Australia, Germany, Italy, Japan, Netherlands, and Switzerland, have taken it on board.
The authors of a breakthrough analysis in the British Medical Journal, say it’s “a clear sign that wasteful medical practices are a problem for all health systems”.
The analysis, titled Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine, is led by top British cardiologist Dr Aseem Malhotra, a consultant clinical associate of the Academy. Co-authors include two of the arguably most important doctors in the UK: current Academy chair, forensic psychiatric professor and dame Sue Bailey, and former chair, paediatric professor Terence Stephenson, now chair of the British General Medical Council.
The content is UK-focused, but has relevance for doctors, patients and the practice of medicine the world over, including South Africa and its faltering National Health Insurance.
At its heart, Choosing Wisely is about stopping overzealous doctors in their tracks – doctors who over treat patients, send them for screening they don’t need, over diagnose and overprescribe drugs, surgery and other treatment regimens that don’t benefit much, if at all, and who keep patients alive when their bodies and minds are screaming to be allowed to “slip this mortal coil”.
It’s not just from doctors who can’t resist the temptation to play God. In a worst-case scenario, it’s doctors following the dictates of the god, Mammon, and making the most money possible out of treating patients.
I like to think that’s the exception rather than the rule.
In best-case scenarios, it’s from doctors rushing in where even angels fear to tread, in their God-like quest to save lives and keep death at bay.
The world over, doctors over diagnose and over treat patients for diseases that may never cause much disturbance, never mind untimely death. They contribute to skyrocketing medical costs along the way.
That makes the BMJ analysis a much-needed injection of life-giving blood into modern medicine, and the authors just the ones to dispense it.
The analysis begins with an historical perspective that makes sobering reading on its own. The authors make the very salient point that the idea of doctors doing medical procedures that do more harm than good is “as old as medicine itself”.
By way of example, they cite Mesopotamian King Hammurabi who proclaimed a law “threatening overzealous surgeons with the loss of a hand or an eye” 3 800 years ago.
A more recent example comes in 1915 cartoon by pioneering Boston surgeon Ernest Codman in which he mocked his colleague’s indifference to the harm they wrought on patients and posed the question: “I wonder if clinical truth is incompatible with medical science? Could my clinical professors make a living without humbug?”
That was at the height of what the BMJ authors call “a surgical vogue for prophylactic appendectomy” – presumably much like the prophylactic mastectomy, oophorectomy and hysterectomy Hollywood actress Angelina Jolie has undergone over the past year.
It’s hard not to get the feeling that little has changed in the intervening years; if anything, things have got a whole lot worse.
“Diagnosis drives treatment,” say the authors in the BMJ, and the tendency to over diagnose and over treat is growing stronger.
They define over diagnosis as when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis”. By overtreatment they mean treatment of these over diagnosed conditions, encompassing treatment with “minimal evidence of benefit”, or that is “excessive (in complexity, duration, or cost) relative to alternative accepted standards”.
The authors say that that hasn’t always been the case in Britain. Even before the introduction of the country’s National Health Service (NHS), they say the British medical tradition was characterised by “late adoption and cautious use of new medicines, procedures, and technologies”.
In recent years, however, they say the UK has exhibited disturbing patterns of variation in use of medical and surgical interventions similar to the US, “though less extreme in absolute terms”.
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