I was talking with a colleague last night whose wife is a doctor. He bemoaned the fact that there is a trend in the UK for closure of hospitals. The automatic reaction many of us have to the cutting of health services is that it’s a bad thing, and that people will lose out as a result. There is of course potential for people to suffer as health services contract, but the relationship between quantity of healthcare and the health of population is not as straightforward as we might think.
Recently, I was reading a piece in the British Medical Journal (BMJ) about some research which finds that in areas where there is more healthcare, more people get diagnosed with illness compared to areas with less available medical care. The overall death rates, however, are essentially the same. One might be tempted to think then the additional medical care in the first setting is keeping sicker people alive. Actually, the research found that the real explanation is that the individuals in the first setting just appear to be sicker. Why? Because they have more interaction with medical care and are more likely to wind up with a diagnosis [1].
Reading this reminded my of another piece of research, also published in the BMJ, which reviewed the effectiveness of ‘health checks’, like having your blood pressure, cholesterol and body weight checked and the appropriate advice or medical care dispensed as a result. 14 studies were analysed. Overall, this sort of health screening made no difference to rates of illness or death [2].
The authors of this study also added that: “Important harmful outcomes were often not studied or report.” It is possible that health checks will pick up ‘problems’ that do not exist in reality or would not have bothered the individual if left alone, but still may result in treatment that can be hazardous or even fatal. Although not a focus in this research, mammography is a classic example of a screening test that has the potential to do much harm.
This week, the BMJ published a letter [3] from a UK General Practitioner (Family Physician)which included this passage:
We feel the consequences of overdiagnosis keenly in British general practice, where a huge part of our workload now revolves around the implementation and fallout of systematic population based screening and risk factor modification. Many of us are wondering if things are getting a little out of hand.
Last month, the BMJ launched an initiative branded ‘Too Much Medicine’ which seeks to “explore the causes and potential remedies of overinvestigation, overdiagnosis, and overtreatment.” I wholeheartedly support this initiative, as it’s likely to help us doctors better understand what aspects of medical care actually do people good. My sense is many cherished practices will fail when viewed objectively. I won’t be surprised if we turn up a few things that are downright hazardous too.
Sometimes, in medicine, the best thing to do is nothing. And I am reminded of a phrase (attributed to one Dr Linda Lewis) that neatly encapsulates this concept and might be headed by doctors more often: “Don’t just do something – stand there!”
References:
1. Wennberg JE, et al. Observational intensity bias associated with illness adjustment: cross sectional analysis of insurance claims BMJ 2013;346 doi: http://dx.doi.org/10.1136/bmj.f549 (Published 21 February 2013)
2. Gøtzsche PC, et al. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345:e7191 (Published 20 November 2012)
3. Treadwell JS. GPs—Do you want to join the debate on overdiagnosis? BMJ 2013;346:f1728[hr]
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