By Marika Sboros
Doctors have always had a name for it – iatrogenic disease. It comes from the Greek word, iatros (doctor). It means doctor-caused disease.
It’s a fancy name for doctor error and its incidence is high worldwide. That’s seen against the backdrop of the Hippocratic oath that doctors swear to “first do no harm”.
In the US, statistics show that iatrogenesis is the “third most fatal disease”. The authors of a well- referenced report on the subject in 2003, are orthodox and complementary medical doctors. They suggest that the situation is far worse and that the medical system is the leading cause of death and injury in the US.
One problem they identify is doctors who are too quick to reach for the prescription pad.
Australian GP, author and speaker Dr Joe Kosterich has firm views about doctors who overdo things. That’s particularly when prescribing drugs. In a blog titled Too much medicine, he makes the case for “de-prescribing”.
The bottom line, says Kosterich, is that too many people are taking too many tablets for too long. Every time doctors have to renew a prescription they should ask fundamental questions, he says. Among these: Is the reason I prescribed this medication still valid? Is this medication still doing more good than harm?
Questions and answers
“We will only get answers if we ask the questions,” says Kosterich.
The purpose of any medical intervention, he says, is to improve patients’ quality of life. Another is to extend life expectancy.
“The closer we get to the end of our lives, the less that life expectancy is likely to be relevant. The fact that scientists do virtually no research on the benefits of most medications in those over the age of 65 bears this out.”
In the UK, the Academy of Medical Royal Colleges recently launched a groundbreaking Choosing Wisely campaign. It’s an initiative that doctors developed in the US and Canada. It has become an international campaign. The aim is to stop the harms of “too much medicine”.
The authors of an analysis in BMJ say that the campaign is “a clear sign that wasteful medical practices are a problem for all health systems”. The content is UK-focused but has global relevance.
British consultant cardiologist Dr Aseem Malhotra is lead author of the analysis. His co-authors include current Academy chair, forensic psychiatric professor Sue Bailey and paediatric professor Terence Stephenson, British General Medical Council chair.
Culture or over-treatment
Malhotra has often warned of “a culture of over-investigation and over-treatment. He calls it “one of the greatest threats to western health”.
In the US, estimates are that a third of all healthcare activity brings no benefit to patients, says Malhotra. This includes excessive use of antibiotics, imaging for “non-sinister headaches” and surgery when “watchful waiting is better”. Crucially, it also includes “unwanted intensive care for patients at the end of life who would prefer hospice and home care”.
In the US, Malhotra says that a fee-for-service model encourages high volume and expensive procedures.
He wrote an article in The Guardian in 2015, under the headline Too much medicine can kill you. In it, he said that “misinformation and fear-mongering” in the medical profession were common. Commercial interests of the pharmaceutical industry are “undoubtedly a root cause”.
Malhotra says that doctors have also exaggerated the benefits of medications. This has led to patients perceiving prescribed drugs as magic pills when benefits are too often “modest at best”.
Choosing Wisely is also largely about stopping overzealous doctors in their tracks.
The BMJ analysis by Malhotra, Bailey and Stephenson begins with an historical perspective. The authors say that the idea of doctors doing more harm than good is “as old as medicine itself”.
Thus, they cite Mesopotamian King Hammurabi who proclaimed a law “threatening overzealous surgeons with the loss of a hand or an eye” 3800 years ago.
A more recent example comes in 1915 cartoon by pioneering Boston surgeon Ernest Codman In it, he mocks colleagues’ indifference to the harm they bring on patients. Codman also poses the question: “I wonder if clinical truth is incompatible with medical science?”
That was at the height of what the BMJ authors call “a surgical vogue for prophylactic appendicectomy”. (For example, the prophylactic mastectomy, oophorectomy and hysterectomy Hollywood actress Angelina Jolie had over the past year bears testimony.)
“Diagnosis drives treatment,” say the authors and the tendency to overdiagnose and overtreat is growing. They define overdiagnosis as when “individuals are diagnosed with conditions that will never cause symptoms or death”. They also say that this is often a “consequence of the enthusiasm of early diagnosis”.
By overtreatment, they mean treatment of overdiagnosed conditions with “minimal evidence of benefit”. Put another way, treatment that is “ excessive (in complexity, duration, or cost) relative to alternative accepted standards”.
That has not always been the case in Britain. Even before the introduction of the country’s National Health Service (NHS), the authors say that the British medical tradition was cautious. “Late adoption and cautious use of new medicines, procedures, and technologies” was the rule.
However, they see a disturbing pattern of variation in use of medical and surgical interventions similar to the US – “though less extreme in absolute terms”.
The National Institute for Health and Care Excellence (NICE) set up in 1999 was in part meant to address “unwarranted variations in clinical practice”. It has identified over 800 clinical interventions for potential disinvestment, the authors say. However, this has not been sufficient to stop doctors from performing “ familiar or ingrained” practices.
Consequently, a prescription for “a different approach to that for introducing new treatments” is required.
The NHS has good systems for evidence appraisal and health technology assessment. However, “better and simpler tools are needed to facilitate informed discussion in clinical settings”, the authors say. This could prevent potentially exaggerated claims for new drugs or procedures that can sway patients.
The Academy of Royal Medical Colleges intends to tackle underlying causes of overtreatment, say the authors. Among these is a culture of “more is better”. Another is the onus and “unbalanced decision-making” it places on doctors to “do something” at each consultation.
Just one effect is doctors offering patients what the authors call “low-hanging fruit”. This includes treatments with “minor benefit and minimal evidence”. This is also “despite the potential for substantial harm and expense”.
Such a culture “threatens the sustainability of high-quality healthcare”, they say. It stems from “defensive medicine, patient pressures, biased reporting in medical journals and commercial conflicts of interest”. It is also from lack of understanding of health statistics and risk.
The Choosing Wisely initiative, therefore, will also look at incentives to limit doctors’ activity.
NICE has produced guidelines for quality measures in both primary and secondary health.
The authors also say that doctors need to make decisions according to their expertise, available resources and, critically, individual patients’ circumstances and wishes. Another problem the authors identify is doctors’ “health illiteracy”. It is well-documented, especially around understanding research data.
Doctors need training in managing unrealistic expectations of patients, say the authors. Doctors also need to avoid misleading patients unintentionally by communicating relative instead of absolute risk or NNTs (numbers needed to treat when assessing benefits of drugs).
The authors quote Gerd Gigerenzer, director of Harding Centre for Risk Literacy in Berlin, in a summary in 2009: “It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks.” This can “protect patients against unnecessary anxiety and manipulation.”
New payment incentives
The authors say that next steps should include different payment incentives for doctors and hospitals. They have also called for:
- Doctors to provide patients with resources that increase understanding about potential harms of interventions, and help them to accept that doing nothing can often be the best approach.
- Patients to feel free to ask questions, such as: “Do I really need this test or procedure? What are the risks? Are there simpler, safer options? What if I do nothing?”
- Medical schools to ensure that students develop a good understanding of risk alongside critical evaluation of the literature and transparent communication.
- Medical students to learn about overuse of tests and interventions.
- Organisations responsible for postgraduate and continuing medical education to ensure that practising doctors receive the same education.
In essence, Malhotra says that the analysis marks the time to “truly wind back the harms of too much medicine”.