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CAMHS won't see you now

GPs need patients to say 'STOP' to overmedicalisation

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The RCGP Annual Conference closed with a debate called ‘My Doctor Makes Me Sick’, raising the serious question of whether we overmedicalise our patients.

Chair of the College, Dr Maureen Baker, challenged us to come up with solutions that might reverse the increase of overdiagnosis and overtreatment that make it nigh on impossible to get to old age without having to sprinkle a handful of pills on your cornflakes every morning.

A list of half a dozen ideas was gathered from suggestions from the conference floor before our chair asked the floor to decide which idea would get the chance to describe their suggestion for a minue.

Much to my surprise, my idea came out on top, and my 60 seconds at the microphone were distilled into this: we need to empower patients to say ‘STOP’.

This really is a serious suggestion. The medical profession is slowly waking up to the dangers of overmedicalisation and we need patients to find their voice if we are to fully rouse ourselves.

This will be no small task. The patient voice is a powerful one, and doesn’t need doctors to prop it up, but usually it arises from a personal story connected to a single disease entity.

If a patient is affected by an unusual cancer, or a rare metabolic disease, and is energised to raise awareness of the condition, then support groups rise up and patients are empowered with doctors barely even knowing about it.

The trouble with overdiagnosis is, most people who are overdiagnosed don’t even know it, and nor do their doctors. Of the 43 men treated for screen-detected prostate cancer, for instance, only one will benefit – the other 42 have been over-diagnosed. But they will all believe they are that ‘one’. How could you put yourself through treatment if you didn’t think it would benefit you?

The issues around overdiagnosis are complex. Doctors can easily be misunderstood as seeking to deny people care. Patients who opt out of treatment or screening are seen as taking a risk rather than evaluating which risk they would rather have - the risk to treat against the risk not to, and the risk to screen against the risk to avoid screening.

We need a patient voice - a pressure group, if you like - that will demand that doctors give them informed consent before paternalistically expecting them to agree to treatment. We need a national presence that stands up for patients who want less medicine, not more. We need patient advocates that won’t rest until screening leaflets are accurate and empower informed choice rather than seek to raise uptake rates for the sake of government statistics. We need an articulate voice that will engage in the media and the tabloid press, and has a thick skin – because if you get involved in this there are people who will think you are mad, bad, or both, and won’t be afraid to tell you so.

What was clear from the conference is that there will be strong support from many grassroots GPs for any patients brave enough to do this. We are fed up of overtreating them and making them ill with too many pills that they don’t want and probably won’t benefit from.

The trouble is, we don’t know how to stop, and we need their help.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68. 

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Readers' comments (9)

  • Or then again, you could just behave professionally in the first place and stop overtreating patients in return for QOF money.

    The onus shouldn't be on the patient - who is seeking a service - to enforce higher standards from the service provider, the onus should be on the provider of the service to behave professionally in the first place.

    Plus, do you really think any doctors would actually listen to patients? That suggestion's a laugh in itself.

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  • 'Plus, do you really think any doctors would actually listen to patients? That suggestion's a laugh in itself. '

    Someone like you is always their to snarl this point out! Oooooh you should behave professionally!!!
    Don't you think we're all fed up of clawing information for QoF to fund our reception, nurses, HCAs, cleaners, heating lighting, rent, rubbish collection and yes our own income. Stop snarling at us annd protest to government - they donn't listen to us

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  • QoF may be partly responsible but also if we pick up illness we naturally want to treat it. Perhaps fear litigation if we don't and there is a problem. Fee for service would surely exacerbate this

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  • " Don't you think we're all fed up of clawing information for QoF to fund our reception, nurses, HCAs, cleaners, heating lighting, rent, rubbish collection and yes our own income'

    Be honest, did you nurses, receptionists, HCAs and cleaners get the same commensurate pay rise you got with the introduction of the 2004 contract?

    QOF isn't compulsory, and neither are high salaries. Sadly, professionalism appears to be optional.

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  • 'Be honest '
    Yes and they hadn't had falling incomes for the years before that.
    We have protected their pay rises by taking pay cuts for the last 7 years as well.
    The income to a practice is the investment to provide a service. Without QoF 1/3 of investment goes along with the staff pay, GP (high) salary (which isn't a salary if you are aware of how GPs get paid.) I can't think why I'm replying really as it's a waste of electrons to someone who cannot see that professionalism has to be supported by resourses, human and finanacial and that some of us are professional and fair to our staff and patients; you'll find most GPs are.

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  • To the irritable anonymous poster;
    QOF was sold as targeting best practice, supported by NICE guidance. We have moved to a situation where legal teams target failure to adhere to guidance in cases against GPs. Aiming to achieve QOF does not represent a lack of professionalism. QOF allows us to exclude patients who decline treatment or are unsuitable for treatment.
    My practice increasingly is to have a discussion about what patients want to achieve regarding treatment. I know many will not take medication if prescribed, some estimates suggest 40% may not. If they do not want a statin, I suggest they stop it or do not start it, but I do believe they may benefit from such treatment. I increasingly wonder what we are aiming to achieve with some of our very elderly patients, particularly with tight diabetic and hypertensive control. One chap informed me his diabetes control was poor as a result of his love of chocolate Brazils, we quickly agreed an annual check rather than the quarterly efforts we were making, might be sensible. He also insisted on his monthly Viagra, intriguingly, when he died a cupboard full of Viagra unopened, was found.

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  • @2:41PM

    But there are systemic pressures on doctors to overtreat.

    Most simply: under-treating is more likely to leave you facing complaints and legal nightmares ("why was nothing done?") than over-treating.

    Unless we can change this asymmetry of penalties, it is unreasonable to ask individual doctors to put themselves at risk by appropriately withholding treatment.

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  • I agree that an appropriate name for an alternative to over medicalistion would be helpful, as a way to describe options to patients and to enable them to engage in the discussion. I used to talk about 'minimal' medicine, now I use 'gentle' medicine - I am aware there is also a 'slow' medicine movement.
    Really in general the key is peronalisation - bespoke options; and what that requires is time our most lacking resource.
    I recently spent an hour trying to discuss with my husband the benefits or otherwise of PSA testing and diagnosis of prostatic cancer and I imagine we will need to revisit it a few times before he makes a truely informed decision.
    It is even more difficult with the frail elderly multicomplex patients polyphamacied up ; an almost evidence free zone. What seems key is to discuss all the uncertainties, risks and possible benefits with the patient and their families so that decisions are made collaboratively. This seems to me to be both the right thing to do and the most likely to avoid litigation.
    If agreement to stop drugs results the outcomes are often good - although the conversation addressing what good might look like could take some of the credit.

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  • there is a real need for change in the way options are presented....the use of simple but effective decision aid tools would help.but are rarely used In cases such asdescribed by Clare many people would fing the drawing up of a 'decision tree' helpful. Pros and cons and the different values individuals put on them can be made visible rather than trying to hold all info in the head

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