A quote from Pulse’s February cover feature has stuck with me. To paraphrase Dr Jennifer Watson, it is much easier to prove medical interventions are working than to prove they’re doing harm. So there is always an ‘assumption that more is better’: it’s easier to advocate for more interventions.
After all, most interventions are supported by some evidence, however weak, and almost always promoted by vocal cheerleaders (some with good intentions), from charities to patients, journalists and pharma companies.
Those advocating less intervention are less prominent. It takes a brave GP to say ‘you’re unlikely to get testicular cancer and you’re wasting a valuable appointment’ in the middle of Movember, for example.
And even if more people did challenge the culture of overmedicalisation, how does one prove the anxiety and procedures generated by 50 incidentalomas from a questionable test outweigh the discovery of a single tumour? Or that time and resources spent on such testing means less time with patients where clinicians can be of greater benefit?
However, Covid has allowed what Dr Watson calls a ‘natural experiment’. There have been fewer scans, fewer unofficial screening programmes and – thanks to the test tube crisis – even a drop in non-urgent blood tests.
Analysing the effects of this ‘natural experiment’ would be a huge undertaking. But it may have shown that reducing unnecessary interventions is possible.
So what are the chances of a cultural shift? I fear the ‘assumption that more is better’ is now ingrained and, indeed, overmedicalisation is an easy route for NHS managers and politicians. We see it in the PCN DES, which obliges GPs to perform ‘opportunistic pulse checks’ for AF when measuring blood pressure.
The result is more work for GPs, not only from the actual policies, but from government rhetoric that drives patients to believe they are entitled to more testing.
Yet overmedicalisation is often the path of least resistance for GPs as well as politicians. Workload plays a part, of course, but the cause is mainly systemic. Perversely, it is in GPs’ best interests – no GP has ever faced a complaint or bad review for sending a patient for tests, yet they often have for not doing so.
There are solutions if the political will is there. First, nothing that even looks like a screening programme should be enacted without approval from the National Screening Committee – and GPs and other clinicians should be able to raise concerns with the committee directly. Second, no contractual clinical incentives should be introduced by the NHS/Government without an independently reviewed impact assessment. Third, the GMC and defence bodies must at least recognise the inherent tension for GPs who try to reduce overmedicalisation in the best interests of their patients. And finally, we need a genuine attempt to research the effects of the reduction of interventions during the pandemic.
However, these will take effort and I fear policymakers will continue to take the easy route, even if it is more costly and potentially harmful to patients.
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Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at editor@pulsetoday.co.uk
READERS' COMMENTS [3]
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The word ‘medicalisation’ was shorthand for social scientist when they meant ‘doctors are taking over the world’. Now big Pharma and HMOs are as likely to get the blame.
‘over medicalisation’ means doctors are taking over the world ‘too much’?
The idea that doctors in the NHS want more work, more responsibility is crazy. There is already too much to do. If there was a profit in it there might be some takers…
You identify several of the groups within society who do want to identify more and more as being the responsibility of doctors. If something is medical then the government doesn’t need to sort out housing, or leisure or food supplies or water. If it is a medical problem I don’t have to diet, or change my job, or accept that I will never be a footballer, or astronaut.
The difficulty we have as a society of individuals in families and groups is that we have developed this handy explanation for everything that is not quite right. If I identify that I can’t kick a ball, there is always a friend or family member to say it’s down to flat feet and ‘you should see a doctor’.
But doctors don’t help themselves or their patients, we want to try to help. We want to make people better, even when their headache is due to them banging it against the wall of the Home Office, or their manager’s office.
When opportunistically checking pulses we’ll do BPs too, and whilst you’re here we might as well take on responsibility for you being overweight, or struggling with reading or concentration, or staying awake. All the time we do this we remove the power and responsibility from individuals and families and employers and society as a whole to sort themselves out. This then gets in the way of us dealing with those things only we can sort out, for those who genuinely do need our help.
Cultural shifts are hard and major shocks can be effective at changing ways, but whilst there is too little agreement on causes and effects I remain sceptical that progress will be in the direction of improvement.
Overmedicalisation is just the result.
Of:
Overregulation
Overlegal narratives
Overpatient power
The powers of physiotherapy, psychology and pharmacology are incapable of solving the emptiness, lonliness, personal neglect and anxiety that lurks within. A label is comforting. It transfers the guilt externally, but solves little. I look forward to the Oxford Handbook of Trivial Hypothetical General Practice, by some experienced Professors. There’s an idea to prove some worth. GPs do sterling work too, of extinguishing the utter nonsense of some public, not patients. Remember there’s a difference.
locally we have been told that we have an unacceptably high cancer pick up rate of 10% for our surgery. it should be 3% according to our CCG. ie we should refer 97 patients with nothing serious for 3 positive diagnoses meaning a 30 to 1 ratio, whereas we manage 10 to 1.
This is a HUGE saving but we are penalised for it.
incidentally a platelet count over 400 has a 10% chance of being due to cancer they tell us, but won’t take referrals for high counts. Where is the logic in this?