Policy bite: The role of family medicine in ‘choosing wisely’.


Prof Amanda Howe, President-elect, writes:

There is a big conversation going on – about a group of concepts variously termed as ‘overdiagnosis’, ‘overmedicalization’, and ‘quarternary prevention’.

WONCA already has members who are active in this debate – presentations at regional conferences have headlined this issue: the RCGP (my own member organization) set up a special interest group on this issue in 2014 and are taking this forward through local workshops and discussions groups (see for example). And the well-known surgeon Atul Gawande has recently entered the debate in the New Yorker. Much of the cost-effectiveness of family medicine in health systems relies on family doctors to manage the initial presentation of new symptoms without excessive tests, medications, or referrals. So this seems an important area for our members to be able to talk about in an evidence-based manner.

The words ‘choosing wisely’ are not only what we aim to do – they have been adopted by initiatives in the U.S.A and Canada, and are being used for a similar campaign in the U.K. To make the right choices in or after a consultation we need the following - sound knowledge, clinical skills, and judgement to get the differential diagnosis right. We need experience in the epidemiology of the setting for clinical practice, as the risks and likelihood of diagnoses are quite different in hospital from community, and indeed in different populations and countries. We also need firm evidence and guidelines that are relevant to our patients: too often guidelines are single – disease oriented, and may indicate treatments and tests that do not take into account the full picture of a family doctor’s patients and their needs. Finally, the health system you work in can create demand that is not evidence based – for example, being paid to send patients to hospital will create more use of medications and referrals than are justified scientifically, and will ‘mis-educate’ patients into believing they need more medical intervention than is good for their health or household expenditure.

In order to avoid over-diagnosis and over-medicalization, family doctors also need time: time to discuss their choices and the reasons for these with their patients, and to educate the community about how ‘wait and watch’ can be used to help with diagnosis. And we must have professional self-confidence and objective justification for our decisions and actions. There is an important role for professional organizations to be involved in leadership, guideline development, and political negotiation to ensure the big picture of patient need and resource allocation is taken into account; also to avoid bias from commercial lobby groups and sectoral financial interests. All WONCA member organizations and regions need to develop their thinking on these issues, to assist our members, and to bring the key findings from new research into our practice and education.

One of my favourite books when I was a medical student was Ivan Illich’s ‘Medical Nemesis’ (see for example) - as I grew older, I understood that my role as a family doctor was less culpable than he had made me fear, but I still retain the goal that the best outcome for our patients is to live as good a life as possible with the minimum input from health professionals and medical treatments; and to be as clear as possible when we have reasons not to intervene. I try in each consultation to answer the following questions in my mind as I take action – “Why I am doing this test / givng this drug / making this referral? How likely is it to add value to to what the patient and I already know we need to do next? If my students or residents saw me do this, could I justify it in terms of modern knowledge? And can it be justified in terms of cost effectiveness?”

Hopefully this discussion will continue across WONCA.
Prof Amanda Howe