A recent report in the The Lancet emphasised the need to address the issue of inappropriate medicine, which includes, but is not limited to, deliberate over-servicing by healthcare professionals for financial gain.

This has a set of implications that range from high financial costs to potential physical and psychological harm of patients.

Many unnecessary procedures and tests being prescribed

About one in five knee replacements done after an arthroscopy to examine the joint in Australia was superfluous, and up to 70% of hysterectomy operations to remove a woman's uterus in the US were unneeded. 

The researchers also found that allergy tests, vitamin D tests, colonoscopies, mammograms, MRI scans for lower back pain, and ultrasound screening for thyroid cancer were some of the procedures often carried out in excess.

Overuse of medicine can lead to exposure of patients to avoidable risks, such as the detection of harmless ‘abnormalities’ in patients or false positives, which require follow-ups that carry more risk. For instance, it was discovered that in South Korea, 9% of a common type of thyroid cancer has been over-diagnosed, that is, it was not malignant. Despite this, many are still being screened and having these cancers surgically removed. This comes with a 2% risk of vocal cord paralysis.

In addition to the unnecessary exposure of risk to patients, overuse of medicine creates a significant amount of unnecessary financial burden, to patients or to the government.

For instance, the cost of MRI scans varies depending on factors like which body part is scanned and where it is done, but they generally cost between SGD$400 to more than $1000. Yet, lower back pain, unless accompanied with other warning signs, often goes away on its own. In the US alone, redundant health screenings accounted for $6.8 billion in medical costs in 2009.

The road to hell is paved with good intentions

The report concedes that a fee-for-service payment system could be fuelling the over-use of medicine in some countries. "Physicians routinely act in conformity with their financial interests. Under fee-for-service payment, many specialties deliver higher volumes of services, distorted referral rates, and lower prevention activity than with fixed payment schemes, such as, capitation and salary," wrote the researchers.

However, it is not the only reason driving the inappropriate use of medicine. Healthcare professionals may fear being sued for not meeting patient expectations or misdiagnosing them.

For example, some patients may expect certain medical procedures to be done, or some physicians might be so frightened of missing a bacterial infection in a child that they prescribe antibiotics for viral infections like coughs and colds that do not respond to antibiotics. Others may not have a clear understanding of what the patient prefers or desires from their seeking of treatment.

Other doctors may not have kept up with the latest research in healthcare, and continue to practise with certain gaps in knowledge of what would benefit the patient. Ironically, there are also those who are influenced by widening definitions of diseases which have been perpetuated by profit-seeking companies.

Such examples include conditions such as ‘pre-diabetes’, new thresholds for high cholesterol, so that more people are being prescribed lipid-lowering drugs with unclear benefits, and new definitions for diseases like chronic kidney disease which has expanded the number of people being diagnosed with it, despite a lack of symptoms.

Communication remains the key

Improving physician-patient communication is one good starting point to prevent rampant overuse of medicine, as physicians are then able to understand their patients’ individual aims and preferences. For instance, some elderly people may prefer not to seek aggressive diagnosis and treatment of a possibly-cancerous lump when they are likely approaching the end of their lives anyway.

Patients are also less likely to be unhappy with their doctors if they are able to voice their concerns and understand where the doctor is coming from. In 2015, the Singapore Medical Council (SMC) recognised that one in five complaints against doctors were due to poor communication between doctor and patient, and have even implemented guidelines to reduce this problem.

Very often, patients do not know enough to find out what they should know. They do not think to question the doctor’s decisions until something goes wrong, when they will then bring up the issue that they felt they were not given enough information on, or sue the doctor. MIMS

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