Choosing Wisely

I heard last month that the Academy of Medical Royal Colleges, which represents all 21 medical royal colleges in the UK, has stated that too many people are being forced into treatments and investigations that can do them more harm than good. The reason behind this is because of GPs’ increasing dependency for income on fulfilling the requirements of the “Quality and Outcome Framework”, which basically pays GPs on their performance. How this works for your average doctor in practice is that his or her pay is linked to the prescription of certain drugs; for example, statins, a category of drugs that are only marginally effective against lowering cholesterol, probably have little beneficial effect in the reduction of heart attacks, and come with a host of undesirable side effects (see my post The Dark Side of Statins for more information).

Doctors’ pay is also linked to their level of participation in screening programmes for diseases such as heart disease, cancer and diabetes. I, for one, was recently invited to have a mammogram. My swift response – no thanks. I am absolutely not going to start crushing sensitive parts of my anatomy and exposing them to ionising radiation. Hospitals also receive money for each patient they treat with set fees for each operation and test they perform. Smart doctors are now starting to see through this. For example, Professor Peter Gotzsche, director of a Danish research centre, has suggested that millions of people should at once stop taking antidepressants, since their long-term risks massively outweighs any potential benefits. He states that the usage of such medications is responsible for the death of half a million pensioners in the Western world annually, in part as a result of the increased suicide rate of people on antidepressants. I have never quite managed to get my head around the fact that antidepressants – drugs that are supposed to in theory make you happier – cause more suicides. How, exactly, does that work?

Despite such prominent experts speaking out, many people still continue to “live” on prescription medication, often at the recommendation of doctors; even though there is often little benefit to these interventions, and quite often the reverse. In an attempt to address the problem, the Royal Colleges are starting a campaign called “Choosing Wisely”, which encourages medical specialities to make a list of common practices which should be stopped because they do more harm than good. It is thought that this will encourage doctors to discuss the “value” of treatment with their patients. What are the benefits? What are the potential downsides? After all, this is the patient’s body; the patient should have a say in what happens to it.

There is of course the long-standing issue of some people not wanting to make a choice. Whilst I personally took responsibility for my own well-being many years ago (luckily armed with the knowledge of medical science as a result of my degree and also my many years of study), relatively few people have the benefit of that information. There will always be those who expect someone else to fix them, and abdicate all responsibility for their less than optimal lifestyle choices which ultimately lead them down the path of disease. There will also be those who possess blind faith in medical science, or lack the knowledge with which to make an informed decision.

If “Choosing Wisely” is going to work, there will have to be a reconsideration of the way in which doctors and hospitals earn their money. Incentives that encourage practices to put a certain number of patients onto statins will have to be removed; it seems, to me at least, completely bonkers that this is the way things were set up in the first place. Invasive investigation of, for example, prostatic enlargement via potentially harmful biopsies to weed out false positives may end up causing more harm than good, and save very few, if any, lives. Some “enlightened” GP practices have even been stating that the way to improve health of male patients is to advise against having a routine PSA (prostate-specific antigen) screening test.

It remains to be seen what the pharmaceutical industry thinks about all of this – after all, if fewer doctors prescribe statins and other long-term medications, their revenue will fall and the shareholders will surely get upset. But with the potential for fewer prescriptions being issued, perhaps the “burden of responsibility” will finally start to move away from an overstretched NHS and taxpayers, and start to fall where it should have been placed in the first instance; with the general public themselves, and with better, unbiased education on how to get healthy and remain so.