Doctors are among the world's most uncritical enthusiasts. They are constantly on the lookout for some magic bullet that can help to alleviate the mountain of pain and suffering that threatens to overwhelm them every day of their working lives.
When a single drug doesn't sort out a health issue, doctors tend to throw two drugs at the problem in the mistaken belief that, if one does some good, then two will double the benefits. For instance, as few hypertensive patients who receive drug treatment achieve good blood-pressure control, medicine has come up with the idea of a hypertensive drug 'team'. This is particularly the case with the elderly, who are often prescribed up to 10 drugs to take at once.
But now even the medical profession thinks this has all gone too far. The Academy of Medical Royal Colleges admits there is now a goodly amount of evidence that the pressure on doctors to 'do something' in their consultations has led to the adoption of numerous prescribing habits and treatments with little or no proven value-part of the reason why the National Health Service (NHS) is currently so overstretched.
To prevent this kind of overtreatment and reduce the harm caused by too much medicine, an initiative was recently launched in the US and Canada called Choosing Wisely.1 So far, Australia, Germany, Italy, Japan, The Netherlands and Switzerland have adopted the initiative, and the Academy of Medical Royal Colleges, an umbrella organization for all of the UK's royal medical colleges, announced in May that Britain is soon to follow suit.
The Choosing Wisely initiative is asking the royal colleges and other medical organizations to identify the tests and procedures commonly used in their speciality that are of little or no benefit. The organizations are also encouraged to work together to figure out their 'top five' questionable tests and interventions, and to encourage their members to stop doing them.
The plan includes promoting the dissemination of these lists and encouraging 'Choosing Wisely conversations' between doctors and their patients.
"These new conversations will rebalance discussions about the risks and benefits of tests and interventions, such that doctors and patients will be supported to acknowledge that a minor potential benefit may not outweigh potential harm," writes Aseem Malhotra, the lead author of the BMJ report on the new initiative.
Malhotra, a heart specialist and consultant clinical associate of the Academy of Medical Royal Colleges, encourages patients to question their treatments, using angioplasty as an example. When a group of patients were told the most recent results of a study showing no true benefits from undergoing angioplasty, only 45 per cent of them elected to undergo the procedure, compared with 69 per cent who chose to go ahead when they weren't informed of the procedure's lack of
Doctors are also being told that, in coming to any treatment decision, they should now factor in the wishes of their patients, rather than bullying them into adopting a treatment they may not want.
The Academy is also attempting to overcome statistical illiteracy among doctors, who often misunderstand the actual benefits of a particular treatment or procedure, or misinterpret the absolute vs relative risks of a treatment.
For instance, in one study of 150 gynaecologists, one-third didn't understand what was meant by the fact that mammograms conferred a risk reduction of 25 per cent, believing the statistic meant that, out of all women screened, 25 per cent fewer would die of breast cancer.
In fact, at best, the relative risks showed that the procedure might prevent one death in every 2,000 women, a statistic that also doesn't take into account all the harm caused by overtreatment resulting from false-positive results.
The Academy does worry that some medical societies will choose the lowest hanging fruit-say, an over-the-counter cough medicine, for their top-five lists, when they should be critically examining major treatments like routine knee replacement and arthroscopy, both of which have evidence of questionable benefit (see our top 10 tests, page 20).
The top five
So which procedures will most likely make it to the top five? According to Peter Gotzsche, director of the Nordic Cochrane Centre in Copenhagen, psychiatric drugs should be top of the list. They are responsible for the deaths of more than half a million people aged 65 and older in the West every year, he says, and these side-effects and deaths are severely underreported.3
Based on a meta-analysis of studies involving a total of 100,000 patients, Gotzsche estimated that there were very likely 15 times more suicides among people taking antidepressants than are reported by the US Food and Drug Administration (FDA).4 Another study showed that antianxiety drugs like benzodiazepines doubled the death rates among patients suffering from anxiety.5 Based on his analyses of death rates in Denmark adjusted to match the statistics from the US and European Union, Gotzsche estimated that these drugs alone cause some 539,000 excess deaths a year in just those two regions. As for drugs for attention-deficit/hyperactivity disorder (ADHD), they trade uncertain short-term relief for long-term harm, he says.6
Bottom line? "We could stop almost all psychotropic drug use without deleterious effect," he says, including antidepressants, ADHD drugs and drugs for dementia, and prescribe a fraction of such drugs currently in use and "then only for acute situations with a firm plan for tapering off".
Malhotra says that overtreatment is nothing new. Some 38 centuries ago in Mesopotamia, a law was passed in which surgeons who were too knife-happy risked losing a hand or an eye. But admitting its own flaws, much less being held accountable for them, is a fairly new concept in Western medicine.
Since our inception in 1989, What Doctors Don't Tell You has been publishing articles warning of the dangers of overtreatment, while also educating the public on how to be more discerning about the drugs and treatments on offer, and WDDTY has taken a good deal of stick from pharmaceutically sponsored organizations for doing so. Now, 26 years later-and undoubtedly because the cost of treatment is spiralling out of control-conventional medicine is finally starting to agree with us.
"Sometimes, doing nothing might be the favourable option," writes Malhotra. Yes, we agree, especially when it has to do with conventional drugs for chronic illnesses.
But there's also a third way. If medicine doesn't have a workable solution for a particular condition, at what point will it consider integrating alternative treatments with a long track record of success for treating the hundreds of thousands of patients not helped by modern medicine?
The chosen many
Which are the top questionable medical tests? Those being mooted include pills for mild depression, routine blood tests and drugs for mild hypertension. But our list of drugs and treatments that haven't been shown to work is far longer. In fact, it's hard to know where to start.
Here are the first tests to put on the naughty step, as together they are responsible for millions of unnecessary procedures.
PSA (prostate-specific antigen) blood test
Produces false negatives in one out of three cases, and has overdiagnosed more than one million men since its introduction in 1987.1
Picks up all manner of benign growths while missing aggressive tumours. For every woman whose cancer is correctly detected, 10 women will go through unnecessary worry (see page 69).
Routine cervical smear tests
Throws up many false positives, which can trigger more invasive procedures, and false negatives-missing cancer that's there.2
Routine dental X-rays
Triples the risk of the brain tumour meningioma and can cause heart disease.3
Routine prenatal ultrasound scans
Gets it wrong so often that up to one in 23 women told by doctors they've miscarried may end up terminating a healthy pregnancy.4
Peripheral bone densitometry
Strong chances of misclassification as osteoporosis, especially if you're under age 65. Test measures only two sites, usually the hip and spine, which means that any 'normal' bone mineral density elsewhere is likely to be missed and misdiagnosed.5
Removing small bits of tissue to diagnose things like cancer has caused infections, punctured nearby organs and scattered cancer cells. With breast biopsies, the risk is one in 15 of having recurrent cancer from 'needle metastasis'.6
Computed tomography (CT) angiography
The use of intravenous dyes and CT technology has doubled the rate of invasive heart procedures, including surgery.7 Ask for the standard exercise bike or treadmill stress test instead.
Axial or spiral CT scans
Just one of these whole-body, three-dimensional CT scans is equivalent to around 500 standard chest X-rays, and undergoing two or three delivers the equivalent radiation levels of the Hiroshima or Nagasaki atomic bomb.8
Blood pressure (BP) cuffs
Drinking alcohol, feeling cold and even the presence of a doctor can distort a BP reading by as much as 5 mmHg. While night-time BP is considered the most accurate predictor of a heart attack, the most accurate reading overall is from continuous 24-hour ambulatory BP monitoring.9
Just a minute, doctor
The Choosing Wisely initiative encourages patients to ask several questions, like 'Do I really need the test?' and 'What happens if I do nothing?'
Way back in 1990, in the second issue of our fledgling journal What Doctors Don't Tell You, we started a campaign urging patients to ask their doctors 10 questions before accepting any treatment. We called it 'Just a Minute, Doctor,' for two reasons. First, before you blindly follow your doctor's well-intentioned advice, you have the right to question what he's told you until you have enough information to make an 'informed decision'. Second, it only takes a minute or two for him to look up or provide information that could save your health or even your life.
Twenty-six years later, these 10 questions are still your best armamentarium against bad prescribing.
1 Is drug therapy really needed for this problem?
2 What will happen if I don't take the drug?
3 What sorts of drugs or substances (including non-prescription drugs, food and alcohol) should I avoid when taking this drug?
4 With what other drugs does this drug have dangerous reactions?
5 What are the known side-effects of this drug, as reported in MIMS or the electronic Medicines Compendium (eMC; both now online)?
6 What are the latest reports in the medical literature about this drug's side-effects?
7 Can I discontinue any other drugs I am currently taking?
8 What is the drug supposed to do for me?
9 How and under what conditions should I stop taking this drug if I notice certain side-effects?
10 If I don't wish to take this drug, what other possible therapies can I consider?
J Natl Cancer Inst, 2009; 101: 1325-9
Am J Prev Med, 2013; 45: 248-9
Cancer, 2012; 118: 4530-7
Ultrasound Obstet Gynecol, 2011; 38: 503-9
BMJ, 2000; 321: 396-8
Acta Radiol Suppl, 2001; 42: 1-22
JAMA, 2011; 306: 2128-36
N Engl J Med, 2007; 357: 2277-84
Lancet, 2007; 370: 1219-29