Joan MV Pons. Head of Evaluation AQuAS
Doing or acting is irresistible; it must be a feature of being human, just like a spring is always ready to bounce, unless we’re talking about contemplators, hermits and stylites (St. Simeon). In medicine and public health we’re more afraid of failures by omission than of failures by commission, so we find ourselves unable to abstain from action. Often we act by asking for analytical or image tests, thinking that these, consisting in a mild pierce or radiation (a lot more if it’s a CT scan) can do no harm, can have no adverse effects. But it’s not quite so. Besides the fact that any unnecessary test (which will not bring new information and if it does will not alter patient management) means throwing money (tax payer’s money), any medical, preventive, diagnostic or therapeutic intervention, in whatever form, brings risks along with any benefits. It can not be otherwise. Needless to say, the main issue is properly knowing how to weigh the pros and cons and how to choose wisely.
The new book by H. Gilbert Welch “Less medicine, more health1“, the same author of “Should I be tested for cancer?” and the better known “Overdiagnosed” is dedicated to disassembling common assumptions about medical practice that inexorably lead to the increased medicalization we are witnessing. One of these beliefs is that acting is always better than doing nothing. Let’s leave aside the ability of human bodies (and other beings) to take care of themselves and to regain homeostasis by natural biochemical defences. Voltaire already said it, when speaking of doctors of the eighteenth century: “The art of medicine is amusing the patient while nature cures the disease.” Nowadays, medicine certainly is much more effective (and safe) than in Voltaire’s age but this leads us to this ever increased desire to make use of it, even for minor and really trivial issues that normally would heal themselves.
However there are other reasons that drive us to act and overact, we could say, well beyond what would be necessary or desirable (again, one must consider carefully). On the one hand, we must not forget, medicine is also a trade, since in many countries (but not all) the doctor is increasingly a salaried professional: places like the US where most doctors have a fee for service, and most private insurers there carry the incentive to do more and more. Even patients who pay their premium private insurance consider that by doing more they get their money’s worth. If funding for the organizations giving the assistance (hospitals, primary care centres) is more activity based than results based, it’s not surprising that most of them pursue productivity (output per input) hospital admissions, visits, etc., forgetting that the important issue is the quality of the result (the outcome). Here it’s obvious that, as economists say, incentives alter behaviour.
Across the Atlantic, defensive medicine that aims to do everything so they don’t miss anything is also prevalent. Here, the liability fever seen on the US has not reached high levels yet, but we’re starting to see many lawyers who have to make a living like everyone else and, as is well known, the complaints can be due to action as well as due to inaction.
It also happens that patients are accustomed to leave the office holding something concrete: a prescription (better a placebo than nothing) or an application for testing or a referral to the specialist. They think this is proper treatment when in fact, the opposite is often the best option. But, after a comprehensive research and exploration, a simple recommendation to wait and observe requires some communication skills that are not taught in schools or during the period of specialization (where training for action actually kicks in). Therefore time is necessary; needless to say, time for consultation and time in general seem increasingly scarce these days (since the productivity is wrongly measured). It may be that doing a particular thing, whether its usefulness is minimal or zero, is the way to compensate for the poor communication.
If we think about the natural history of some diseases and about the statistical regression to the average, it’s not surprising that one may end up feeling better with time. Unfortunately we end up believing in the post hoc ergo propter hoc fallacy i.e. that the intervention, however ineffective, was the cause of the improvement. Many alternative and complementary medicines are based on this false causal interpretation, together with the placebo effect of the therapist and the ritual paraphernalia that surrounds them, generate dramatic improvements in personal suffering also conditioned by the stressful and competitive lifestyle we lead.
Let’s go back to start: the greatest fear of omission, of not acting. Perhaps the reason is that particular desire, shared by professionals, family and friends, to be able to say that all that could be done, has been done. If they tried hard, we can say they have a defence or an alibi; also that abusive use of warlike metaphors in cancer, and not only the weapons employed (biological, chemical, nuclear), but also the usual obituary: “He died fighting.” We know very well that the issue is not that, on the contrary: the crucial point is what we all want our death to be like: quiet, without suffering, surrounded by the closest and dearest friends and family.
To counteract this tendency to act, to do more and more, to overact as mentioned, whereby the effect called “cascade” can amplify ad infinitum, professionals and patients should ask a simple question: what would happen if we did nothing?
1 Gilbert Welch H. Less medicine, more health. 7 assumptions that drive too much medical care. Beacon Press. Boston. EUA, 2015