Can doing nothing sometimes be the best approach?

cwDr Amit Arora is a Consultant Physician and Geriatrician at University Hospital of North Staffordshire, Stoke on Trent and an Honorary Clinical Lecturer at Keele University.

You may have seen recent stories in the national media about a new campaign launched by the Academy of Medical Royal Colleges called Choosing Wisely. It says that patients should be encouraged to ask if tests are really needed, that doctors should discuss potential harms of treatment with patients, and calls for experts to develop lists of common practices that should be stopped.

Originally a US initiative, now launched in the UK, its aim is to get doctors to stop using interventions with no benefit, and to help tackle the threat to human health posed by over diagnosis and the waste of resources on unnecessary care.

Unnecessary care occurs when people are diagnosed and treated for conditions that will never cause them harm. As geriatricians we are only too familiar with the harmful effects of polypharmacy be it drug-induced hypotension leading to falls or recurrent hospitalizations due to adverse drug reactions etc. etc. A culture of ‘more is better’, has significantly undermined the age old tradition of ‘Do no Harm’.

Participating organisations will be asked to identify five tests or procedures commonly used in their field, whose necessity should be questioned and whose risks and benefits should be discussed with patients before using them.

These will be compiled into lists, and the “top five” interventions for each specialty should not be used routinely or at all.

They say it is time for action “to translate the evidence into clinical practice and truly wind back the harms of too much medicine.”

The twin of over-diagnosis is of course under-diagnosis, under-treatment and under-care. It is probably most obviously noted in mental health services and possibly to some extent in older people as well though in a slightly different context.

It brings several questions:

Is this new movement the beginning of a cultural shift towards shared decision-making, rather than merely identifying a “do not do” list? Will NICE and other organizations be crucial in developing such tools?

Getting this nuanced narrative correct for the media and the public is crucial. At a time when NHS is in a transitional phase, will this movement be perceived as a top down cost cutting measure?

Could this be the biggest step towards patient-centred medicine in the UK or could it fizzle out in a lot of arguments about this treatment and that?

The only way it can succeed is if it genuinely involves patients at every stage and every level. It’s trying to get doctors to have a better understanding of the real benefits and harms of treatments and care pathways and how to explain and discuss these with people in a way that meets their concerns, goals and preferences.

BGS has been working with the Picker institute towards developing PREMs. Would this become a key quality measure?

It will mean establishing mutual trust and treating guidelines as advice and not as tramlines. We need to re-establish the value of wisdom and kindness and look at how best to teach and disseminate these, as well as teaching and disseminating the best evidence to guide practice.

Geriatricians are well placed to do this. This is a movement which geriatricians could give a serious thought.

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