A major new initiative called Choosing Wisely has been launched by the Academy of Medical Royal Colleges. This initiative aims to address a culture of over-medicalisation in health, where treatments are prescribed – not always with much clinical value – when other, better solutions may exist.
Alongside a major public campaign to explain why certain tests or treatments won’t be effective, the initiative plans to publish a collected list of tests and treatments. This might include X-rays for back pain or the prescription of statins for people aged 75 and older to lower cholesterol and prevent heart disease. Regarding statins, it appears there is no clear evidence that high cholesterol leads to heart disease, and it is more likely that older will suffer serious side effects from statins. Sue Bailey, head of the academy, said the aim was “to encourage doctors to have conversations with their patients” about unnecessary treatments and tests and “taking a grown-up approach to healthcare and being good stewards of the resources we have”.
Choosing Wisely is already established in the US and Canada and there are similar UK campaigns such as the British Medical Journal’s Too Much Medicine. Yet is has already been met with mixed reaction. While some have argued that “consumerism-creep”, where pills are seen as an answer to all ills, needs to be combated in the NHS, others have said it could jeopardise safety. The Patients Association has voiced concerns about “widespread rationing”. Even the Guardian was not immune from describing the project as heralding an “unprecedented crackdown”, that would lead to medical professionals withholding treatments.
So why are people worried about not being able to access treatments that are no good for them?
Give me something
One one hand, a patient is a consumer who exercises choices. We are informed, authoritative, and have the capacity to make decisions based on interests most immediately apparent to us. Margaret Somerville calls this “intense individualism”: the institutionalisation of a sense of disconnection from each other – choice for its own sake. Yet the negative reactions reveal a far more interesting correlation that has been less explored: the effects of illness or injury on a patient’s plan of action.
One of the most solid principles that patients rely on is that medical treatments, in general, will get us back to health. Medicine, and more broadly science, delivers the goods. This certainty is something that often allows us to cope with ill health. By limiting access to certain medical interventions, even though they may be of little value, this certainty is rocked and so too the trust we place in being healed.
A question of trust
Patients’ beliefs that prescriptions and treatments are one of the most reliable ways back to health is essentially a principle of trust in science and medical treatments. This is the opposite of the anti-vaccination movement; instead of being against interventions because of the lack of trust, here that trust is so strong that taking away interventions, even limited ones, is seen as a cause for concern. If this is true, then we need to understand why we as patients are so ready to trust medical treatments, but are often much more wary to trust the people who aim to restore us back to health.
Both trust in medical treatments and trust in medical professionals fit into what Somerville calls “earned trust”. Both must be built up by generating a relationship, even if that relationship has different component parts to it, and may be earned in slightly different ways: treatments earn our trust most effectively by restoring our health and medical professionals earn our trust by demonstrating they have our best interests in mind. Though they are in a position of power, they (rightly) involve patients in the decision-making process – and this is one way to rebalance the professional-patient relationship.
Take the example of patient who does come in asking for an x-ray or an MRI scan for lower back pain. The patient may believe such scans will get to the heart of the problem and reveal what is really causing the pain. They might think this is the best plan of action to begin to get them back to health. But the cause of the pain might be because of a variety of factors other than severe structural or neurological problems, what those scans are designed to detect. And it is here the medical professional can earn the patient’s trust, by reassuring the patient that such scans may not be needed, and explaining why in a manner the patient can understand. All of this portrays the medical professional as knowledgeable, responsible, and authoritative.
If Choosing Wisely is about “taking a grown-up approach to healthcare” as Bailey said, then ultimately patients must take responsibility for choosing wisely in regards to all aspects of their healthcare. But this cannot really be achieved unless it is understood that trust facilitates choice. The academy’s public campaign may prove fruitful – if it is successful in helping the public understand why treatments are limited and are shown why their certainty is better placed in other treatments or scenarios.