Guest post: "We must ask our doctors: 'is this treatment necessary?'"
Professor Sue Bailey argues that doctors need to stop 'over-treating', and says patients must be empowered to make informed decisions about their care
Chair of the Academy of Medical Royal Colleges
Posted on: Fri 15-May-15 16:48:24
(92 comments )
The other day, a colleague told me the following all too common story. A few weeks ago a 90 year-old woman was admitted to a local hospital with multiple problems. Not surprising perhaps for someone who has lived so long. One of these problems (though not the reason she was admitted) was having high levels of cholesterol, which as most people know, can lead to heart disease.
The guidelines, which we doctors are supposed to take into account at all times, say that one way to alleviate this problem is to prescribe statins. We know too that many people who are prescribed statins can experience an upset stomach or headache or feel sick for the first few weeks. That elderly lady died two weeks after the prescription from an unrelated disease, which was almost certainly going to kill her anyway. What really upset my colleague was that the last two weeks of her life were spent suffering from the side-effects of the statins, which the doctor had prescribed in absolute good faith and in absolute accordance with the training and the guidelines set out by the body that advises doctors on which intervention to make.
This story neatly illustrates the challenge we face in medicine every day: medicine, for all its high-tech advances in the last few decades, is not and will never be an exact science. No patient is ever the same, no symptom is ever identical and few treatments can ever be called perfect or entirely without risk. Most of all, medicine should be about people, and making decisions with them that are best for them. This is why my organisation, The Academy of Medical Royal Colleges, has launched an initiative called 'Choosing Wisely', which is about three things.
Patients need to be more aware of the fact that one person having a test or treatment may remove the opportunity for other more pressing cases where the need may be greater or more genuine.
Firstly, we want doctors to understand that a pill, a test, or surgery – which by definition can be risky – may not always be the best solution for the patient. In my own field of psychiatry, we've long known that an episode of mild depression should be treated, in the first instance at least, with a prescription of some form of exercise the patient can do, often in conjunction with talking therapies. The problem is, most GPs aren't trained in psychiatry. How are they to define 'mild'? We know that anti-depressants aren't without risk, yet they continue to be doled out fairly easily, sometimes long after the episode of depression has passed, and studies reveal huge regional variations in the amounts of anti-depressants that are prescribed.
The second point is about patient expectation. Those people who are in and out of a doctor's surgery or their local A&E, convinced they have this or that illness and demanding a whole series of tests for them or their children, are not a myth. Our job is to manage their expectations or those of their parents. Of course we should commission the tests if in the clinician's view they are appropriate, but what we shouldn't be doing is ordering them just to put the patient's or parents' mind at rest. No healthcare system in the world has unlimited resources; our job is to be good stewards of the resources we have. Patients need to be more aware of the fact that one person having a test or treatment may remove the opportunity for other more pressing cases where the need may be greater or more genuine.
Finally, Choosing Wisely is about the doctor and patient having an open conversation together about what the risks and benefits are. It's about enfranchising patients and encouraging them to ask their doctor if this treatment or test really is necessary for them or their children. It may be that when they are fully informed they still want to go ahead. That's fine - we certainly don't want to ration treatments. But it may be that once they have all the information, they want a different option.
On this point there is some remarkable evidence: a recent study conducted into the use of stents, a common procedure used to widen narrowed or blocked arteries in the heart, showed that when patients were given basic information about the procedure, 69% were happy to have it carried out. But when patients were given full information about the likely impact and the extent to which a stent can remedy ongoing problems and extend life, just 46% of patients opted to go for the treatment.
Choosing Wisely will, I hope, help us to reach decisions together. Rational decisions based not on what we can do for the patient, but instead on what's best for the patient. And that's a decision we need to start taking together.
By Professor Sue Bailey
I think it's a massive, massive step forward in health care.
I'm afraid I'm far more worried about people not getting treatment they should from their GPs - or getting it too late, to worry about people getting statins who might not benefit.
How very patronising to GPs. We recognise 'mild' depression because, unlike psychiatrists, we deal with it every day. And not, I might add, by using anti-depressants. Come and do a day at my surgery and then tell me about my over prescribing.
At my GP you have to fight to even see someone. They were happy to give me cortisone cream and Cetraben for DD's eczema but were taking my diagnosis that it was eczema - they did not wish to see her. Regarding her Cmpi and other food allergies, the attitude is that children grow out of it so why bother testing. Ok, but what about ensuring she has sufficient nutrients? Likewise when I needed surgery. Took 4 consultants with four different diagnoses (all wrong) before someone agreed to operate, discover what it actually was and resolve the problem.
Under-treating is a far bigger problem in my experience.
A rethink regarding overtreatment, overinvestigation and trying to treat the untreatable is so long overdue and will save a lot of unnecessary suffering and heartache.
IMO and IME what is needed is time for good communication, time to explain why what is being done or not done, time to listen and to come to decisions about end of life care with the person, their family or carers.
Time is what we don't have.
Secondary care doctors (my DH is one) on a regular basis slag primary care off (my DH knows better than to be one of them ), medical students don't want to go into primary care and there is a massive crisis in GPland already which is only going to get worse, not better in the next 5 to 10 years.
Less tickbox medicine and less 'documentation' of what we do rather than actually doing more, less politics in healthcare and more honest advice on what can and what cannot be achieved, would be a start.
So, I agree with the sentiment of the OP, but don't think it reaches far enough and will of course enrage anybody who's ever been misdiagnosed or had to wait for treatment.
Agree with others that it is under treatment that is more of a problem in my experience. GP has acted as a 'gatekeeper' of NHS resources and both times that I truly needed them, prevented/ delayed me from getting the care I needed. On the other hand, my 96 year old grandma is prescribed antibiotics over the phone (again, inappropriately) - at last count, it was 7 courses of abtibiotics this year....
My GP's seemed to feel I just needed placating! Despite near weekly visits with a long list of ongoing issues. I eventually requested a private referral and 11 months later was diagnosed with Hodgkin's Lymphoma and required a donor bone marrow transplant. I feel GP services are far from adequate, to the point they wouldn't even consider a 32 year old who had had a baby in the last 12 months would be anything other than postnatally depressed, instead I probably had only a few months left in me! Not to mention the expense of my treatment in the end. So yes your style of approach is already well and truly in action to a very negative effect!
9% of the total NHS budget go to primary care where 90% of patient contacts happen.
And of course I meant 'engage'
This is about far more than our own individual good, bad or ugly experiences, it's about making a limited budget work for most people to maximum benefit. The concept of the NHS was always about the 'greater good' and not about the 'individually best'.
Oh no, I did mean 'enrage' - sometimes I don't trust myself to make sense when I do… [confuse]
There's massive pressure to take statins and all sorts of other drugs, steroids, god knows what. We've all experienced the writing of a prescription before we've even finished speaking. Much better if the GP actually makes eye contact (ie looks away from the computer screen) and listens to what the patient has to say.
Yep, listening as where it's at, but that's time consuming and not captured by a tick box, so the powers that be are not interested in that. 'Soft skills' are having a lip service paid to, but are not funded.
To make it quite clear, this is not about my individual income, this is about human resources, physical space (we have been fighting tooth and nail for new premises for 7 years, having been overcrowded for more than 15) and TIME. Time is costly.
But Pacific, doesn't this Guest Post signal a change in that? They DO want doctors to listen, after all.
The statins mentioned in the OP are just a tiny example of so-called evidence based medicine being applied without common sense.
Ageing populations, polypharmacy and complicated multi morbidity happening at the same time as shrinking doctor numbers and increasing privatisation of the health service is frightening me tbh.
I think the idea is that doctors spend the time that they currently spend writing prescriptions on listening instead. So it's not "as well as" but "instead of".
Oh, I'm listening, I am.
Explaining to a loving older daughter that I think we should stop her very aged and demented mother's statin takes time: time to explain that a drug given for prevention of heart disease is not going to achieve anything in a 95 year old, time to explain we are not stopping it because of 'savings' (Simvastatin now costs pennies), time to help her understand we are not not treating her because there is no treatment for old age and advancing dementia, reassuring her that she is not a bad daughter for allowing us to stop a drug as this feels uncaring and neglectful to her and she secretly feels guilty that she put her mum in to a nursing home.
Funded is 'Cholesterol <5'.
Yes, but they are precisely talking about a culture change which will be really good for patient health. For years it has been impossible to say: "I don't want to take the tablets, thanks." We've got a whole bloody culture based on drug addiction.
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