Doctors issue warning about overtreating patients

Behind the Headlines

Wednesday May 13 2015

Sometimes doing nothing may be the best option

Are some doctors guilty of dishing out useless drugs?

"NHS tests and drugs 'do more harm than good'," is the headline in The Telegraph, while The Guardian warns: "Doctors to withhold treatments in campaign against 'too much medicine'."

Both of these alarmist headlines are reactions to a widely reported opinion piece from representatives of the UK's Academy of Medical Royal Colleges (AMRC) in the BMJ about the launch of a campaign to reduce overdiagnosis and overtreatment in the UK.

However, the article does not suggest that doctors should "withhold" effective treatments, or say that all, or most, NHS tests and drugs do more harm than good.  

Who wrote the opinion piece?

The piece was written by a group of doctors representing the UK's AMRC. The academy represents all medical royal colleges in the UK.

The authors include Dr Aseem Malhotra, consultant clinical associate at the AMRC, Dr Richard Lehman, senior research fellow at the University of Oxford, and Professor Sir Muir Gray, the founder of the NHS Choices Behind the Headlines service.

The piece marks the launch of the Choosing Widely campaign in the UK. The campaign is already underway in the US and Canada. Its purpose is to ask medical organisations to identify five commonly used tests or treatments in their specialities that may be unnecessary, and should be questioned and discussed with their patients.

An example given on the website for the US Choosing Wisely campaign is the routine use of X-rays for first-line management of acute lower back pain. As these types of cases usually resolve by themselves, the use of X-rays could be seen as both a waste of time and money.

The piece is published as an open-access article, meaning it can be read for free online in the peer-reviewed medical journal BMJ. Read the article in full on the BMJ website

What arguments does the piece make?

The piece argues that some patients are diagnosed with conditions that will never cause symptoms or death (overdiagnosis) and are then treated for these conditions unnecessarily (overtreatment).

In addition, the authors say, some treatments are used with little evidence that they help, or despite being more expensive, complex or lengthy than other acceptable treatments.

They say overdiagnosis and overtreatment are driven by "a culture of 'more is better', where the onus on doctors is to 'do something' at each consultation".

The idea that doing nothing may actually be the best option could be a concept alien to many doctors as a result of medical culture and training.

The article says this culture is caused by factors such as:

  • NHS England's system of payment by results, which rewards doctors for carrying out investigations and providing treatment – though a case could be made that this is more of a problem in private healthcare systems, such as the US, where the incentive to provide often expensive investigations and treatment is much higher
  • patient pressures, partly driven by lack of shared information and decision making with patients
  • misunderstanding of health statistics, which means doctors, for example, overestimate the benefits of treatment or screening

Overtreatment matters, the authors say, because it exposes people to the unnecessary risk of side effects and harms, and because it wastes money and resources that could be spent on more appropriate and beneficial treatments.  

What evidence do the authors use to support their argument?

The authors cite various studies and sources to support their arguments. They point to patterns of variation in the use of medical and surgical interventions around the country, which do not relate to a need for these procedures.

They say the National Institute for Health and Care Excellence (NICE) has identified 800 clinical interventions commissioners could stop paying for because the available evidence suggests they do not work or have a poor balance of benefits and risks.

It should be pointed out the BMJ piece did not report specific evidence estimating how common overdiagnosis or overtreatment are in the UK as a whole.

The authors also note that a study of the effect of the GP payment system introduced in 2004 – which provides financial incentives for a range of activities, such as recording blood pressure, testing for diabetes and prescribing statins to people at risk of heart disease – found these tests and treatments are now more common, but this did not seem to have reduced the levels of premature death in the population.

Finally, the piece cites a study that found fewer people chose to have an angioplasty when told that, although it can improve symptoms, it does not reduce the future chances of a heart attack, compared with people who had not been told this explicitly.

It is important to point out the evidence presented in this article did not seem to be gathered via a systematic method (a systematic review). This means there could have been evidence that countered the authors' argument that was overlooked or not included.

The authors acknowledge there is no evidence that the Choosing Wisely campaign has had any effect in reducing the use of low-value medical procedures in the US. 

How accurate is the media reporting?

While the actual articles in the UK press are, in most cases, accurate, some of the headlines are alarmist and not particularly useful.

The Independent gives a good overview of the campaign and sets it into context, with information from NICE and examples from the US.

Several of the newspapers highlight specific tests and treatments that might be targeted by the campaign. For example, the Guardian reports that, "Doctors are to stop giving patients scores of tests and treatments, such as X-rays for back pain and antibiotics for flu, in an unprecedented crackdown".

This is premature – the first step that will be taken by medical organisations such as the royal colleges is to identify the top five lists of treatments or tests they consider to have dubious value, before discussing whether to reduce their use or, in some cases, not use them at all.

Once these have been identified, the piece calls for sharing this information with doctors and patients to help them discuss the benefits and harms of the identified treatments and tests more fully.

Does it make any recommendations?

The AMRC makes four recommendations:

  • Doctors should provide patients with resources to help them better understand the potential harms of medical tests and treatments.
  • Patients should be encouraged to ask whether they really need a test or treatment, what the risks attached to it are, and whether there are simpler, safer options. They should also be encouraged to ask what happens if they do nothing about their condition.
  • Medical schools should teach students better about risk and the overuse of tests and treatments, and organisations responsible for postgraduate training should ensure practising doctors receive the same education.
  • Those responsible for paying hospitals and doctors should consider a different payment system that doesn't encourage overtreatment.

In addition, the authors say the clinical, patient and healthcare organisations participating in the Choosing Wisely campaign are to work together to develop top five lists of tests or interventions of questionable value. They will then promote discussion about these interventions.

For an up-to-date, unbiased and entirely transparent overview of your options for testing or treating a particular condition, go to the NHS Choices Health A-Z.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Analysis by Bazian

Edited by NHS Choices

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