Choosing Wisely – Is our society over-medicalised?

15 Nov 2012

Is our society over-medicalised? A new campaign, Choosing Wisely, has been developed to combat the overuse of medical resources in the US. Is Australia exempt from the problem? by Tara Rivkin (HGI Insight Nov 2012)

We’ve all heard it: in prosperous nations we over-diagnose and over-treat. Advanced diagnostic tests are able to identify illnesses that historically weren’t considered so and discover ones that once would have been missed; screening tests alert us to conditions we do not yet have. These types of advancement are, on the whole, a good thing; diseases are more treatable than they ever have been and more preventable. But can medical care be excessive? Research literature into the patient and systemic harms of overtreatment has been emerging of late, mostly in the United States but also here in Australia. Such research looks at the costs of unnecessary testing to the healthcare system-“the economics of ubiquitous screenings”¹ as editor of Reuters Health, Dr. Ivan Oransky, has called it- and the avoidable treatment of, and consequential stress to, the patient. The benefits of certain tests are questionable, according to Oransky; “it’s…not clear if it’s doing more harm than good by testing every man over 50 for a PSA each year.”²

Have we fallen into a sort of progress trap in which medical sophistication and awareness is producing certain harmful byproducts? Has society been over-medicalized? In a sense, we have a proverbial telescope to our insides. We look harder than we ever have in the past for medical problems and in doing so, often find things that may diverge from the norm, but that won’t necessarily harm us.

As Ray Moynihan, Senior Research Fellow at Bond University, wrote in an article in The Conversation (which commenced on September 10 as a series in the publication on the over-diagnosis epidemic),

“…over-diagnosis happens when people are diagnosed with diseases or conditions that won’t actually harm them. It happens because some screening programs can detect “cancers” that will never kill, because sophisticated diagnostic technologies pick up “abnormalities” that will remain benign, and because we are routinely widening the definition of disease to include people with milder symptoms, and those at very low risk.”³

Oransky echoed this in a Ted Talk earlier this year. He discussed the proliferation of pre-conditions and sub-clinical conditions and the rise of an apparently at-risk population. He also noted that the mostly fee-for-service medical system encourages doctors to do more testing and procedures and fear of liability propels them to go above and beyond, even if this isn’t necessary or is even harmful. The cost of treatment for pre-conditions, as well as their side effects, tells a worrying story, he explains. “Every year we’re spending more than two trillion dollars on healthcare, and yet 100,000 people a year are dying not because of the conditions they have, but because of the treatments that we’re giving them.”⁴

For these reasons, the American Board of Internal Medicine is piloting a campaign called Choosing Wisely, which champions the appropriate use of healthcare resources amongst physicians and increased consumer knowledge amongst patients. The program’s aims are as follows:

“…to promote conversations between physicians and patients by helping patients choose care that is:

• Supported by evidence

• Not duplicative of other tests or procedures already received

• Free from harm

• Truly necessary”⁵

The most significant initiative within the campaign is the recommendation by nine specialty boards of forty-five procedures that are, at present, over-performed and should be questioned by patients. The specialties involved-the American Academy of Allergy, Asthma & Immunology; the American Academy of Family Physicians; the American College of Cardiology; the American College of Physicians; the American College of Radiology; the American Gastroenterological Assn.; the American Society of Clinical Oncology; the American Society of Nephrology; and the American Society of Nuclear Cardiology-each proposed five tests that now contribute to the full list, released on April 4.

Choosing Wisely by no means suggests that these tests and procedures are universally wasteful; rather, the program highlights the need for discerning and cautious doctors and patients in the wake of profligate spending and the medical side-effects of excessive treatment. As Christine Cassel, MD, CEO of the American Board of Internal Medicine and the ABIM Foundation (which developed the campaign), has said, “It’s about cutting waste; it’s not about rationing.”⁶ For example, cardiologists suggest doctors don’t “perform annual stress cardiac imaging or advanced non-invasive imaging as part of routine follow-up in asymptomatic patients” as it may “lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes.”⁷

Cassel and James A. Guest, JD, cite estimates in an article they wrote for The Journal of the American Medical Association of at least 30% of all healthcare spending being wasted on medical resource overuse.⁸ An essay in Inside Story argues that assuming Australia is exempt from this problem is a mistake.⁹ Indeed, we are entering the fray; there was a meeting on the topic in Coolangatta in April and there is an international conference, in part organised by Bond University, in the United States next September.

There will undoubtedly be much more to come locally on the topic.

¹Dr. Ivan Oransky interviewed by Shiv Gaglani (2012). ‘Is Society Becoming Over-Medicalized? Interview with Executive Editor of Reuters, Dr. Ivan Oransky,’ medGadget, http://medgadget.com/2012/07/is-society-becoming-over-medicalized-interview-with-executive-editor-of-reuters-health-dr-ivan-oransky.html

²
Dr Ivan Oransky in ‘Is Society Becoming Over-Medicalized?’
³
Ray Moynahan (2012). ‘Preventing over-diagnosis: how to stop harming the healthy,’ The Conversation, http://theconversation.edu.au/preventing-over-diagnosis-how-to-stop-harming-the-healthy-8569
⁴
Ivan Oransky, TED Talk, April 2012, Washington DC.
⁵
Choosing Wisely, ABIM Foundation, 2012, http://choosingwisely.org/
⁶
Christine Cassel quoted in Emily Berry (2012). ‘Choosing Wisely list is about good judgment, not curtailing care, medical societies say,’ American Medical News, http://www.ama-assn.org/amednews/2012/04/16/bisa0416.htm
⁷
Recommendation by the American College of Cardiology, Choosing Wisely
⁸
Christine Cassel, James A. Guest. ‘Choosing Wisely: Helping Physicians and Patients Make Smart Decisions About Their Care’, The Journal of the American Medical Association, 307:17, May 2012, p. 1801.
⁹
Melissa Sweet (2012), ‘Overtested, overtreated and over here,’ Inside Story, http://inside.org.au/overtested-overtreated-and-over-here/