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.
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.