Can doctors reduce harmful medical overuse worldwide?

CAN DOCTORS REDUCE HARMFUL MEDICAL OVERUSE WORLDWIDE? A rapid response to the BMJ
19.07.2014

If the problem of medical overuse is to be solved, or at least ameliorated, doctors and patients must be involved. Only at its conclusion does the article note: ` The meeting was keen to emphasise that the point of Choosing Wisely, a campaign begun in the US in 2012, is shared decision making - that is, better conversations among doctors and patients`.

Participants considered a long list of commonly overused interventions within topics such as imaging, pre-operative testing for low risk patients, cancer screening, and prescribing. No doubt the evidence is available from wide-scale trials and meta-analyses in order to enable advice to be given on desired population levels of intervention. And, we are told, the Choosing Wisely campaign aims to promote a culture change by facilitating `dialogue between specialists, GPs and the public`. But an abstract, impersonal, albeit science-based` public` perspective is quite different from that held by an individual patient with an illness; and it is patients who come into the consulting room, patients with whom the conversation must take place.

The dynamics of this need unpicking if any progress is to be made. Patients and their doctors start with different premises about the nature and purpose of the consultation. For patients, the imperative is to optimise their situation by reducing uncertainty about their condition (for better or for worse) , and to have this happen quickly: cognitive dissonance is one of the most difficult conditions for humans to tolerate. Doctors use a differential approach to diagnosis which may have to take place over a number of consultations; and their imperative is to do no harm, reducing interventions of any sort to the minimum necessary. The two positions can be, but mostly are not, in major conflict. But a conversation, indeed a negotiation, must be based on exploring the differing perspectives, both to move things on in the short term, and to achieve greater concordance to the treatments offered in the future. If not, doctors are more likely to be pressured to over-service patients, and very possibly to acquiesce, especially with those patients who are the most articulate.

`Negotiation` is part of everyday life for most people in one guise or another - even babies do it! But often, in the past, it seemed to be suspended when patients approached overly-paternalistic health providers and institutions. However, it long been recognised by social theorists, such as Pareto in the late nineteenth century (1), that `optimisation` is at the core of many human interactions, where one party`s situation cannot be improved without making another party`s situation worse. Each of the participants in a conversation will have a view on what is best given the circumstances. Doctors and patients are also subject to this dynamic; but when there is a bilateral monopoly - a single consumer and single provider as with the NHS - negotiation can easily be skewed.

Beyond the general, the situation for GPs and specialists may differ because of the quite different approaches they employ in managing patients. Marinker (2) has stated: the role of the GP is to tolerate uncertainty, explore probability and marginalise danger. With specialists he says: they aim to reduce uncertainty, explore possibility and marginalise error. Which of these behaviours most closely align with the patient imperative? Clearly it is the latter; and this serves to emphasise the difficult role that the GP has in any country where they are expected to act as gatekeeper. It identifies that it is at this first point of contact the dynamics of negotiation must be fully explored and best understood. Good negotiation, followed by a partnership in decision making, is especially difficult when patients and doctors have asymmetric knowledge, and the more so when patients increasingly `consult` the internet.

Choosing Wisely has usefully provided a list of five questions for patients to ask doctors: Do I really need ... ? The risks? Simpler, safer options? And if I do nothing? The cost? Doctors in more recent years have begun to get used to issues of this kind being raised, but probably more so in counties with a dominant private sector such as the US, or where insurance only partially covers costs. In the UK such evidence as there is suggests more and more often consultations are mediated against a background of an internet search. The questions set for patients by Choosing Wisely have a much-reduced currency because internet entries tend to introduce the patient more to possibilities than probabilities. One bright light in this firmament is that current UK medical students are being trained to help patients to pose these very questions.

Reporting as early as 1981 on a Canadian College of Family Physicians study from Vancouver, `Family Medicine in a Consumer Age` (3), I noted that: `Feelings on the part of consumers of a need for autonomy, power and a possibility of negotiation regarding many aspects of care in family medicine are clear.` Even then, the age of Lancelot Spratt was well past; and the Parsonian 1950s analysis (4) of patients recumbent with passivity was subject to serious reappraisal. Now the challenge is more complex. Governments encourage patients to complain. Consumer and patient groups lobby on social media for the adoption of emerging innovations. Patients embedded with their computers believe they have instant remedies for their ills. Front-line doctors will not find it easy to reduce harmful medical overuse worldwide under these circumstances.

914 words
1. Pareto, V. Cours d`Economie Politique. Dorz: Geneva. 1896
2. Marinker, M. The Medium and the Message, Patient Education and Counselling, 2000; 412:117-25.
3. Warner, M.M. The consumer and family physician relationship: power, autonomy, compliance and negotiation. In Cogswell, B.E. and Sussman, M.B. Family Medicine: A New Approach to Health Care, Marriage and Family Review, Spring/Summer 1984; 4, 1/2: 135-155.
4. Parsons, T. The social system. Glencoe: The Free Press. 1954,428-473

In response to Jecko Thachil's recent comments, I would like to add the observation that it is my experience that doctors seldom scrutinise the results of full blood counts that are performed daily (or more than once daily). Accordingly, laboratories should refuse to process such requests unless sanctioned by a senor clinician who should give reasons to justify full blood counts of that frequency. Unfortunately, however, it is no longer a realistic option to expect doctors who are trained in a high-tech environment to undertake a "good...physical examination", given the fact that it has become a badge of honour, even in the columns of the BMJ, to denigrate the practice of clinical examination.

Considering the rampant enthusiasm of medical scientific societies to join the project Choosing Wisely and to define the five high-risk practices of inappropriateness, it seems appropriate to point out the main obstacles regarding the implementation of the project.

Problems on the demand side

Choosing Wisely project postulates the active involvement of patients (“alliance between doctors and citizen-patients”) to promote discussion with their clinicians about the need—or lack of it—to perform this or that test or treatment. Such "alliance" requires a "minimum" of clinical education on the patient’s side, in order to allow him (or her) to express preferences and to interact with physician about the utility or futility of the proposed diagnostic and /or therapeutic service. Today this condition cannot be easily met for the great majority of citizen-patients since between 70 and 85% of the population believe that medicine is an exact, or almost exact, science (1).

Consequently, the dominant physician-patient relationship will still remain "paternalistic", where the patient, not having technical knowledge, slavishly follows, without interaction, the suggestions of his (or her) doctor. Last, but not least, it is worth asking to what extent citizen-patients will perceive the "inappropriateness" of a medical service as an implicit rationing or the prelude to an explicit one.

Problems on the supply side

The project and the list of services at risk of inappropriateness should not become a "fig leaf" for the participating scientific societies. To avoid this major adverse event it seems mandatory for every society to implement (i) a monitoring system able to inform to what extent individual physicians will actively join the project and (ii) an evaluation program to follow the trend of the prevalence of practices - identified as being at high risk of inappropriateness - over time. This could be very easily implemented at a hospital level, while it would require both an investment and an innovative organizational framework at the territorial level.

In reporting the most common overused medical services in the US Choosing Wisely campaign it was highlighted that the majority of listed items targeted “imaging”(2). This fact points out the need to promote strong links and to build up consensual actions between radiologists and other medical professionals who prescribe radiological images.

It would be highly desirable to enhance the radiologists’ role in order to reduce the overuse of imaging tests prescribed by other medical specialists. Should radiologists play more a role of gatekeeper rather than of service provider (3)?

Last, but not least, more numerous and more courageous lists having a real impact on clinical practice should be developed and published.

Two other questions could be seriously taken into account to avoid the suggested “fig leaf” effect.

To what extent the propensity to avoid medical practices at a high risk of inappropriateness will be "honored" when that choice collides with economic individual or corporate incentives?

To what extent the fear of litigation (defensive medicine) will influence the appropriateness of prescribing behavior?

In conclusion, the Choosing Wisely project has aroused in many countries the enthusiasm of physicians and of other health professionals, as it is based on their responsibility in the appropriate use of resources.

We believe that the success of the project will, to a large extent, depend in particular on the sense of responsibility and on the ethical involvement of the participating physicians. The active involvement of patients, in fact, is likely to remain a mythical desire for the vast majority of them and for many years to come. However, the project can be a powerful tool for the community health education. In order for this to happen, though, it should be supported by an intense and intelligent communication campaign addressed to the general public and not only to elitist groups of consumers. In fact, the physician-patient encounter may not be sufficient to change habits and behaviors that already deeply entrenched (2).

References:
(1) Domenighetti G., Grilli R., Liberati A. Promoting consumer's demand for evidence-based medicine. International Journal of Technology Assessment in Health Care 1998; 14: 97-105

(2) Morden NE, Colla CH, Sequist TD, Rosenthal MB. (2014). Choosing Wisely - The Politics and Economics of Labeling Low-Value Services. N Engl J Med 2014; DOI: 10.1056

(3) Saurabh Jha MB. From Imaging Gatekeeper to Service Provider - A Transatlantic Journey. N Engl J Med 2013; 369 (1): 5-7

Clinical skills are the backbone of reducing harmful medical usage worldwide. A passionate clinician would relegate only those cases to investigations where they are really indicated and exercise patience in dealing with them. A common cold can be effectively managed by supportive treatment without resorting to the latest, costly antibiotics. Malpractice by some tarnishes the image of other doctors and demeans the patient -doctor relationship. Care givers and investigating authorities must work together and decide judiciously as to the management and necessity of cumbersome, costly and many a times unnecessary investigations.