Less is More: The dangers of too much medicine

Posted on 16th January 2015 by Danny Minkow

Key message

Many people throughout the world are rightly concerned that they are not getting enough of the quality healthcare they need.  Yet, there is also a growing concern that the opposite issue of overtreatment, and too much medicine, is actually causing harm, as well as increasing costs of care.

What is the problem?

There is good evidence that in some developed countries, particularly in the US, healthcare providers are overtreating. This means people receive too many unnecessary treatments, tests, and screenings. Additionally, there is also frequent overdiagnosis of many medical conditions.

One example of excessive screening is the annual health check-up for otherwise healthy adults. A recent New York Times article referenced a Cochrane Review that looked at General health checks in adults for reducing morbidity and mortality from disease. The researchers looked at 14 randomized control trials (RCTs), including over 182,000 participants. They concluded that general health checks are unlikely to be beneficial. The costs of these health checks alone are estimated to be in the billions of US dollars.

Of course there are numerous examples of screenings that do catch undiagnosed or underdiagnosed health issues, and those benefits are clear to the patient. However, while there are many screenings that identify some health problems and potentially save lives, these same screenings can also cause direct and indirect harm.  For example, the use of X-rays or CT scans emit harmful radiation, and is considered a direct harm. Indirect harm is caused by false positives on health screenings. That can lead to unnecessary patient anxiety, follow-up tests, and treatments, which may again have harmful side effects. All of this could have easily been avoided and, of course, contributes to the high cost of healthcare.

Here is another recent New York Times article, this time by Aaron E. Carroll, which features many more examples of the harmful effects of “doing more” for patients. He says “More is expensive. More sometimes does no good. Sometimes, more is even harmful. When our policies and care ignore these facts, we all suffer.” Dr. Carroll has also recently produced an excellent Healthcare Triage episode on the Overuse of Antibiotics.

So how did it get this way?

There are many reasons why healthcare providers frequently overtreat. Some of those reasons include increased focus on preventative care, financial incentives, direct-to-consumer marketing of pharmaceuticals (in the US), disease mongering, overuse of expensive technologies, defensive medical practices, or even just the patient’s or doctor’s expectations to just ‘do something’ or ‘do more’. All of these issues could lead to overtesting and overtreating.

What can we do about it?

In her blog Less is More, Dr. Otte suggests a “just right” or “Goldilocks” approach. This ‘not too much and not too little’ approach aims to strike a healthy balance. She suggests healthcare providers use the right amount of medicine, focusing on patient-centred, evidence-informed practice. That way, we can just focus on doing more of the things that are known to have positive outcomes with patients.

The good news is that the much of the medical research community clearly realizes there is a serious problem. Several major medical journals have even dedicated special sections of their journals solely to articles discussing the harms of overtreatment, including JAMA Internal Medicine’s Less is More collection and The BMJ’s Too Much Medicine Campaign. The BMJ also sponsors a conference focusing on Preventing Overdiagnosis.

Thankfully, this “less is more” idea seems to be a movement gaining serious momentum in the medical world with a view to “winding back the harms of too much medicine”.

“Like the evidence based medicine and quality and safety movements of previous decades, combatting excess is a contemporary manifestation of a much older desire to avoid doing harm when we try to help or heal.”
–  Dr. Godlee

Conclusions & comment

As students of healthcare, we are about to step into a system that may tend overtreat. Even though we might not like to admit it, it’s likely that each of our respected disciplines overtreats, overtests, or overdiagnoses in some way or another.

I would love to hear from other students- is this topic of overtreating even discussed in your respective healthcare program?

Further Reading

A further look at the sometimes counter-intuitive conclusions brought by looking at the evidence for health checks:

• David Carroll www.students4bestevidence.net/nhs-health-checks-whats-the-evidence/

 Links

• Aaron E. Carroll Healthcare Triage YouTube channel
• Journal of the American Medical Association (JAMA) Internal MedicineLess is More topic series
• The British Medical Journal (BMJ)’sToo Much Medicine campaign
• Jessica Otte’s Less is More Blog and website http://www.lessismoremedicine.com/
• BMJ video Harms of Overtreatment
• Preventing Overdiagnosis Conference http://www.preventingoverdiagnosis.net/

References

Grady D, & Redberg RF. (2010). Less is more: How less health care can result in better health. Archives of Internal Medicine, 170(9), 749–750. doi:10.1001/archinternmed.2010.90

Krogsbøll, L. T., Jørgensen, K. J., Grønhøj Larsen, C., & Gøtzsche, P. C. (1996). General health checks in adults for reducing morbidity and mortality from disease. In Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. Retrieved from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract

Moynihan, R., Glasziou, P., Woloshin, S., Schwartz, L., Santa, J., & Godlee, F. (2013). Winding back the harms of too much medicine. BMJ, 346(feb26 2), f1271–f1271. doi:10.1136/bmj.f1271

Thompson S, Tonelli M. General health checks in adults for reducing morbidity and mortality from disease [editorial]. Cochrane Database of Systematic Reviews 2012 17 Oct;10:ED000047 http://www.thecochranelibrary.com/details/editorial/2723031/General-health-checks-in-adults-for-reducing-morbidity-and-mortality-from-diseas.html

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