Is it time to diverge from the 'more is better' mindset?
WINNER - SANDS COX CHARITY ESSAY PRIZE 2019
Overtreatment and overdiagnosis have become prominent features of contemporary medicine and westernised healthcare systems. This duo has pervaded drug and medical technology industries, medical research, guideline production and clinical practise. A geriatric falls clinic gave me many ‘pills for thought’ to reflect upon and emphasised the notion of ‘less is more’. In the UK, 17% of admissions in the older population are attributable to adverse drug reactions; a prevalent issue in the face of our ageing population1.
The phenomena of overtreatment are evident beyond the parameters of the Geriatric clinic room and shadow wards and General Practices; from the threat of antibiotic resistance to the harms of unnecessary tests and treatments. The prescribing cascade is a slippery slope encountered daily; an archetypal example is amlodipine causing calf swelling, leading to a diuretic being prescribed, which in turn reduces potassium and is subsequently treated with a further drug carrying its own side effects, and so on. The list of medications increases, as does the risk of noncompliance, dizziness, confusion and falls. Patients become hospitalised and discharged on a new cocktail of drugs, layered on top of the old and a few weeks later, we come face-to-face with the same patient again on the wards. Are we doing more harm than good?
By extending the range of what is considered abnormal and being reliant on theoretical risk calculated by risk scores, pharmaceutical companies have seized opportunity to expand their market and maximise profit. It is easier for us to take pills as ‘quick-fixes’ rather than take conservative approaches to improving health. Pharmaceutical vested interest also brings to light the issue of underreporting harmful effects of new intervention and overreporting the benefits – we should be reminded to use our critical thinking hats when interpreting drug data. Let us be reminded of the discrepancies between journal publications and concealment of primary data during the TAMIFLU debacle. Data sharing and transparency, as promoted by the BMJ’s campaign, are essential for true medical advancement and patient safety. The overdiagnosis of ADHD serves as a potent reminder of the medicalisation of childhood behaviours outside the supposed norm. Labelling and medicating children instils the belief within them that they are ‘abnormal’, not in control of their behaviour and that answers can be found in pills.
What can we do to combat overprescribing? Improving quality of life should be at the forefront of care. Patients should be maximally benefitting from treatment and not suffering ‘unnecessarily from illness caused by excessive, inappropriate or inadequate consumption of medicine’2. The first step begins with justifying every prescription a patient is on and ensuring doses are titrated appropriately. We are entering an era where doctors need to engage with the art of deprescribing. Barriers to deprescribing, including limited knowledge and skills in the area, fears of consequences and lack of time and resources to monitor patients after reducing or stopping medication should be addressed. ‘Big Pharma’ has led us to become over-dependant on medications and has instilled some fear of stopping medications in both physicians and patients.
As physicians we are taught how to investigate, prescribe and treat, but less on how to deprescribe and promote a healthy lifestyle. Progress has been made in de-implementation, observed with the ‘Choosing Wisely UK’ campaign. To further support this clinical need, deprescribing guidelines should also be developed to enhance clinician confidence.
The discontinuation of sleeping pills is a common example; these need to be weaned down slowly, otherwise rebound insomnia may occur and lead patients to think they cannot cope without them.