How to avoid unnecessary interventions
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3304 (Published 13 August 2009) Cite this as: BMJ 2009;339:b3304
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“Avoiding unnecessary intervention makes sense for patients because
almost all treatments and tests have the potential to do harm.”(1) With
one more recent issue dedicated to “unnecessary interventions”, it may
indeed be “fair to say that the BMJ tends toward less rather than more
medicine.”(2)
It appears there is consensus that we need less medicine than we are
currently indulging in. But then the question is how much less is less?
Well, in the aftermath of the COURAGE trial and the overwhelming evidence
accumulating that revascularization may indeed not add anything over and
above the patient’s own will to turn his lifestyle around to control or
even reverse his coronary artery disease, how much angioplasty or CABG is
less? Well, all the peer reviewed evidence in most stable cases
overwhelmingly suggests: ZERO.
Why has “Primary Health Care” failed? “Health for All by 2000”
perhaps lost to oblivion? Why “Prevention” is a far cry? Why caring for
the sick is everything that health care has become? And, why practice of
medicine has been reduced to maintaining and nurturing preventable and
reversible morbidities amongst those who have them, and allowing these
diseases to inflict those who don’t yet have them? The answers may not be
easy, or at least not too palatable for our sickcare society that has
gotten so addicted to the medical breakthroughs that keeps 80% of
preventable and reversible lifestyle diseases on lifelong drug treatment
regimens. It’s high time we got bold enough to bring down the threshold
of less medicine, and redefine the meaning of “Prevention” and PHC beyond
merely preventing diseases, to preventing the adverse effects of lifelong
therapeutic dependence. So how low the threshold can realistically go?
My response to the question is a question for each one of us to think and
answer: Why not Rx Zero?
References:
(1) Godlee F. How to avoid unnecessary interventions. BMJ
2009;339:b3304, doi:10.1136/bmj.b3304.
(2) Godlee F. Less medicine is more. BMJ 2009;338:b2561,
doi:10.1136/bmj.b2561.
Competing interests:
None declared
Competing interests: No competing interests
I read Fiona Godlee's article with interest(1) and began wondering
just what made an investigation unnecessary especially as regards
suspected ankle fractures. The Ottawa ankle rules are inherently
subjective as bony tenderness can be interpreted in many different ways.
In reality the harm of a few extra radiographs when there is clinical
doubt is probably far less than missing the occassional ankle fracture. I
think common sense is far more valuable than a strict adherence to
guidelines, after all when a displaced ankle fracture is missed and early
osteoarthritis ensues, the potential cost to the health service is huge.
1. Fiona Godlee. How to avoid unnecessary interventions. BMJ 2009;
339: b3304
Competing interests:
None declared
Competing interests: No competing interests
Dear Fiona Godlee,
“80% of the final accurate diagnosis and one hundred per cent of the
future management strategies could be arrived at, at the end of listening
to the patient and reading the GP referral letter. This can only be
refined 4% by all physical examinations and 8% more by all the
investigations including PET!” This was the startling new revelation in
one of the finest papers published by some of the leading lights of
British medicine at that time, Mitchell, Hampton, Harrison, Pritchard, and
Seymour, in one of their prospective double blind studies of medical
outpatients published in 1975 in your own journal. (1) This led to a nice
letter by the then editor of Postgraduate Medical Journal, Barry
Hoffbrand, entitled “away with systems review-plea for parsimony.” If you
investigate every one very thoroughly all of them would need some
intervention, drugs or invasion. Clinical medicine on the bedside,
practised by well trained humane physicians, can drastically cut down
interventions. “If you listen to your patient long enough, s/he will tell
you what is wrong with her/him,” Lord Platt in 1949.
This must have been lost in the cacophony of myriads of hi-tech
selling articles in all journals every day, including yours. George Orwell
was right when he wrote that: “There are some ideas so wrong that only a
very intelligent person could believe in them.” My friends make fun of me
whenever I exhort the virtues of bed side medicine and its benefits to the
common man. Your editorial talks about the NHS in trouble. Please spare a
minute to think of the vast sea of humanity below the poverty line in the
“so called third world” where the present top heavy hi-tech stuff has
become a curse. Many smaller countries trying to ape the western top heavy
technological medicine are going broke by the day! Hi-tech medical care is
being sold in those countries as health care. In fact, the right word
should be health scare system. A cursory look at the present media hypes
of the so called swine ‘flu is a good example. New hidden secrets of that
pandemic are leaking to the media daily.
Overdosing of drugs is another big scandal. Uffe Ravneskov analysed
the absolute risk reduction and NNT of anti-hypertensive and anti-
cholesterol drugs published in 2002 in the BMJ which, if understood by
patients and prescribing doctors, could bring down their sales to just
about 5% of the present business! (2) These truths are all brushed under
the carpet in our CME system funded by the industry. Let us try to have
the right type of medical education to our future doctors to undo this
damage. The present converts can never be converted again to sanity.
Yours ever,
Bmhegde
1) Hampton JR, Harrison MJG, Mitchell JRA, Prichard JS, Seymour C.
Relative contributions of history-taking, physical examination, and
laboratory investigation to ... BMJ. 1975; (May):486-489.
2) Ravnskov, surviving without treatment. BMJ; 2002: 1353a. eletter 18th
June 2002.
Competing interests:
None declared
Competing interests: No competing interests
Nothing works..
My old partner John Bignall had a very useful witticism for the
difficult patient, whether she be the self-destructive denier or the
entitled-demander:-
Patient: I've tried the yellow pills, the pink ones, the exercises,
the injections, and the operation.. and Nothing Works !
Doctor: OK - try nothing ...
Competing interests:
None declared
Competing interests: No competing interests