The more we learn about the problem of too much medicine and what’s driving it, the harder it seems to imagine effective solutions. Winding back unnecessary tests and treatments will require a raft of reforms across medical research, education and regulation.
But to enable those reforms to take root, we may need to cultivate a fundamental shift in our thinking about the limits of medicine. It’s time to free ourselves from the dangerous fantasy that medical technology can deliver us from the realities of uncertainty, ageing and death.
We’re all ill now
A growing body of evidence shows that when it comes to health care, we may simply be getting too much of a good thing. In the United States, it’s estimated that more than US$200 billion a year is squandered on unnecessary tests and treatments. In the United Kingdom, senior medical groups are calling on doctors to reduce all the wasteful things they do. And in Australia, the Choosing Wisely campaign recently kicked off with lists of unnecessary and harmful health care.
Not only are we overusing pills and procedures, we’re creating even more problems with “overdiagnosis” by labelling more and more healthy people with diseases that will never harm them.
Screening programs targeting the healthy can detect potentially deadly cancers and extend lives. But they can also find many early abnormalities that are then treated as cancers, even though they would never have caused anyone any symptoms if left undetected.
The common ups and downs of our sex lives are often re-labelled as medical dysfunctions. Older people who are simply at risk of future illness – those with high cholesterol, for instance, or reduced kidney function, or low bone mineral density – are portrayed as if they were diseased.
The doctors expanding disease definitions and lowering the thresholds at which diagnoses are made are often being paid directly by the companies that stand to benefit from turning millions more people into patients.
What’s driving all this excess is a toxic combination of good intentions, wishful thinking and vested interests – fuelled by sophisticated diagnostic technology that often offers the illusion of more certainty about the causes of our suffering. It’s as if we’re seeking technical fixes for the fundamental reality of human existence – uncertainty, ageing and death.
Fundamental shifts in thinking
Indeed, intolerance of uncertainty has been suggested as among the most important drivers of medical excess. Doctors order ever more tests to try, often in vain, to be sure about what they’re seeing – to be more certain. But disease and the benefits and harms of treating it are inevitably fraught with uncertainty because we’re trying to apply knowledge derived from populations to unique individuals.
More broadly, uncertainty is the basis of all scientific creativity, intellectual freedom and political resistance. We should nurture uncertainty, treasure it and teach its value, rather than be afraid of it.
No matter how much the marketers of medicines try to make us feel broken by the mere passing of time, ageing is not a disease. Disease definitions that equate “normal” with being young are fundamentally flawed and require urgent review.
The doctors who defined osteoporosis, for instance, arbitrarily decided the bones of a young woman were normal, automatically classifying millions of older women as “diseased”. Similarly, those who defined “chronic kidney disease” have classified the normal changes in kidney function that happen as many of us age as somehow abnormal. Brace yourself for the impending arrival of pre-dementia, the latest attempt to medicalise the ageing process.
In all cases, the people who wrote these definitions included those with ties to pharmaceutical companies – reinforcing the need for much greater independence between doctors and the industries that benefit from expanding medical empires.
Rays of hope
Everyone must die and everyone, patients and doctors alike, is more or less fearful of dying. So, it’s perhaps not surprising that we so often turn to biotechnical approaches rather than paying real attention to the care of the dying – a core purpose of medicine.
What we tend to forget is that medicine cannot save lives – it can only postpone death. Yet we persuade ourselves it might somehow keep extending our lives, and we come to view almost every death as a failure of medicine.
Doctors persist with treatments for the dying well after these have become obviously futile, often with the support of patients or their families. Deep, difficult and necessary conversations about death and dying are only possible in a context of trust, which becomes increasingly difficult as health-care systems are ever more fragmented.
But, there are many positive signs of change within medicine. The Choosing Wisely campaign mentioned above is a partnership between doctors and wider civil society. And it’s now an international movement to wind back excess medicine.
A new approach called shared decision making is promoting much more honest conversations between doctors and the people they care for, embracing uncertainty about benefits and harms, rather than peddling false hopes. Another new approach among GPs called quaternary prevention is urging doctors to protect people from unnecessary medical labels and unwarranted tests and treatments.
Perhaps all these new movements will re-establish doctor-patient trust, helping us reduce fear and embrace uncertainty, and end the pretence that medicine can cure ageing and even death. Biomedical science has made our lives immeasurably better, but it’s time to accept that too much medicine can be as harmful as too little.
Former president of the UK Royal College of General Practitioners, Dr Iona Heath, co-authored this article. Dr Heath will deliver a free public lecture on the problem of “Too Much Medicine” at the University of Sydney this Wednesday night, August 5.
Ray Moynihan is helping organise the Preventing Overdiagnosis conferences. He wrote this article in close collaboration with Dr Iona Heath.
Authors: The Conversation