When less is more: Responding to overtreatment

There is much about medicine that is good. But as Fiona Godlee points out, it is possible to have too much of a good thing. Evidence for potential harms of overtreatment, both to individual patients and to society, should not be ignored.

All treatments have the potential to do harm, as well as good. Yet we are often surprised by evidence of harm from medical interventions, and not always swift to respond. In diabetes, for example, we have seen evidence that tight glycaemic control is associated with increased risk of death. Recently, questions have been raised about the harms of GPL-1 agonists among people with diabetes. The harms arising from unwarranted investigation and over-diagnosis can also include psychological harms such as increased anxiety or depression.

Overtreatment is not just about the potential harms to individual patients. Societal harms are also relevant. These include the medicalisation of society, such that people who are relatively well come to consider themselves ill; or the pathologising of normal aging among older adults. Overtreatment has ramifications for the financial sustainability of our national health system. The public purse funds many activities – to which as taxpayers we all contribute – the more we spend on health, the less there is available to spend on pensions, or on education. We must spend wisely, and learn to balance our books. Overtreatment works against us here.

Reducing overtreatment is important when viewed from a number of perspectives: prevention of harms to individuals, harms to populations, and the fundamental sustainability of public finances. But where to from here?

1. Practice minimally disruptive medicine

One useful suggestion made by Carl May and colleagues is to instigate a treatment regimen that provides the target effectiveness, with minimal burden on the patient. We might start by encouraging more clinicians to ask themselves “what is the effective yet least burdensome treatment programme for this person, with their health conditions, and life context?”

2. Recognise uncertainty

Managing uncertainty is central to the practice of medicine – but few patients have a good understanding of this. Health professionals who are able to communicate uncertainty well to patients, will help to avoid unwarranted investigations and over-diagnosis.

3. Improved shared decision-making

Shared decision-making helps to promote treatment choices that take into account the patient’s preferences, needs, and capacity. It could also help to reduce overtreatment and maximise patient quality of life, for example by reducing polypharmacy and by ensuring patients’ do not receive treatments they don’t want.

4. Learn from others

Considering the potential harms arising from overtreatment is not new. Some areas of medicine, such as palliative care, are already quite good at recognising and trying to avoid overtreatment. There may be much to gain from sharing what is learnt in one area of medicine with colleagues in another.

5. Train our doctors carefully

To offer treatment is part of an ethos that reaches back to the history of medicine as a professional practice, as embodied in the Hippocratic oath. The imperative to ‘act’ is also fundamental, and, as doctors have themselves have observed, it can be difficult to share or even acknowledge a patient’s journey into the lonely realms beyond hope.

Reducing harms from unwarranted interventions requires a fresh approach. Perhaps the most difficult challenge may be changing public and professional perceptions of what constitutes ‘good medicine’. Over-diagnosis and overtreatment are foreign, even counter-intuitive to many people, including some doctors. Part of the remedy for overtreatment might be physician training that emphasises the value of reflecting on your own practice, and acknowledges that when considering whether to offer investigation or treatment – just because you can, doesn’t (always) mean you should.

What to learn more?

May, C., Montori, V.M., Mair, F.S. We need minimally disruptive medicine. BMJ2009;339:b2803
Godlee, F. Too much medicine. BMJ 2013;346:f1328
Godlee, F. Overtreatment, over here. BMJ 2012;345:e6684
Cassel CK, Guest JA. Choosing Wisely: Helping Physicians and Patients Make Smart Decisions About Their Care. JAMA. 2012;307(17):1801-1802.

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