Re: Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz
I share Dr Llewelyn’s frustration that the views expressed in this essay do not offer us any clear way forward. Like many others [1, 2], Woloshin and Schwartz clearly recognise the complexity of factors affecting decisions and preferences about health care choices, listing a multitude of potentially important influences driving variation, including everything from commercial influences to the availability of services, as well as the professional and wider cultural factors that are likely to be in play.[3]
More research documenting and assessing the harms of ‘too much medicine’ is welcome and necessary, as is the proposed integration of patient preferences into decision making processes. However, given the complexity of the problem, it is unlikely that EBM and SDM alone can save us. Proposed reforms must take into account factors including the realities of prevailing attitudes to risk, the uncertainty (and controversy) in the existing evidence base and existing practices and structures in our health care systems. Lisa Rosenbaum is right to suggest that “understanding *why* we deliver unnecessary care deserves scientific enquiry” (my emphasis) [4]. Without developing our understanding of how important contextual factors interact to affect doctors’ and patients’ attitudes, preferences and reasoning, we are unlikely to be able to address the resulting variation in care.
Rapid Response:
Re: Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz
I share Dr Llewelyn’s frustration that the views expressed in this essay do not offer us any clear way forward. Like many others [1, 2], Woloshin and Schwartz clearly recognise the complexity of factors affecting decisions and preferences about health care choices, listing a multitude of potentially important influences driving variation, including everything from commercial influences to the availability of services, as well as the professional and wider cultural factors that are likely to be in play.[3]
More research documenting and assessing the harms of ‘too much medicine’ is welcome and necessary, as is the proposed integration of patient preferences into decision making processes. However, given the complexity of the problem, it is unlikely that EBM and SDM alone can save us. Proposed reforms must take into account factors including the realities of prevailing attitudes to risk, the uncertainty (and controversy) in the existing evidence base and existing practices and structures in our health care systems. Lisa Rosenbaum is right to suggest that “understanding *why* we deliver unnecessary care deserves scientific enquiry” (my emphasis) [4]. Without developing our understanding of how important contextual factors interact to affect doctors’ and patients’ attitudes, preferences and reasoning, we are unlikely to be able to address the resulting variation in care.
1. Pathirana, T, Clark, J, Moynihan, R. Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017;358:j3879. https://doi.org/10.1136/bmj.j3879
2. Hofmann, B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. Eur J Epidemiol 2014;29;9:599-604. https://link.springer.com/article/10.1007%2Fs10654-014-9920-5
3. Woloshin S, Schwartz LM. Overcoming overuse: the way forward is not standing still. BMJ 2018;361:k2035. https://doi.org/10.1136/bmj.k2035
4. Rosenbaum L. The less-is-more crusade—are we overmedicalizing or oversimplifying? N Engl J Med2017;377:2392-7. . https://doi.org/10.1056/NEJMms1713248
Competing interests: No competing interests