Quote of the month: “We doctors should admit that our behaviour has not been in favour of patients. We have caused a massive resistance to antibiotics. We are making poor buy drugs that most times are expensive and unnecessary." Massimo Serventi (Paediatrician, Tanzania; member of HIFA Project on Information for Prescribers and Users of Medicines)
Over-diagnosis and over-treatment of patients is increasingly prevalent not only in low- and middle-income countries but also in high-income countries. It is often cited as a consequence of entrenched and mistaken beliefs that, in healthcare, 'more is better' and 'new is better'. A recent BMJ article Too Much Medicine: What is driving this harmful culture? inspired HIFA members to share individual experiences, examine why the 'harmful culture' has grown to such proportions and offer practical solutions.
Massimo Serventi is in no doubt that, when it comes to over-diagnosis or over-treatment, “patients are never, never in fault: in fact they are victims”. As the author of our Quote of the Month, he places the responsibility squarely with doctors and other frontline healthcare providers who ignore national clinical guidelines and “prescribe for profit and not for medicine” - a view echoed in the above-mentioned BMJ article. The latter states that 'health professionals and hospitals frequently have financial incentives to perform more investigations or treatments for their patients, favouring increased and sometimes unnecessary care'. Massimo goes on to identify the pharmaceutical industry as the chief driver of this betrayal of patients’ trust, by spreading the erroneous belief that a pill or injection will always solve the problem. In his view, the antidote to Too Much Medicine is good professional practice: providing and documenting both a suspected and differential diagnosis, and treating the patient according to readily-available national clinical guidelines. This will put an end to “the adoption of extravagant drugs prescribed by extravagant doctors”.
For Rebecca Ngalande (midwifery consultant, Bangladesh; HIFA member), however, sociocultural factors, including upbringing, shape patients’ perceptions of what constitutes good healthcare. “In most African societies like where I come from”, she states, “people have been sensitised that the more drugs you get the better”. She paints a picture of patients not as victims but as individuals with very specific ideas not just about quantity, but also quality, both of drugs and dispensary. First-line drugs such as paracetamol are generally assumed to be ineffective and, according to Rebecca, people prefer “to spend money at a private clinic/hospital because it is assumed they will get better drugs as compared to government/public hospitals.” This perception is reinforced when public hospitals are under-staffed, with one healthcare provider faced with overwhelming numbers of patients, many of whom will knock on doors and shout if they feel that a consultation is taking too long. With no time for meaningful discussion, the provider will often just issue a prescription and, as Rebecca points out, “sometimes the patient actually tells the provider the type of drug she/he wants"
Even when the doctor-patient relationship is properly managed, over-diagnosis and over-treatment can still occur. Amb Prince Emma Onyero (Medical Director, God Heals Hospital, Nigeria) gave the example of patients with diverse healthcare conditions who believe that medication of any kind will cure them completely. As a result, they may not feel it necessary to describe all of their symptoms, leading to incorrect diagnosis and treatment. Kenneth L Chanda (Associate Consultant and Lecturer at National Institute of Public Administration Zambia) pointed out that over-prescription could also occur when doctor and patient speak different languages, resulting in errorrs in the patient’s history. Unsure of the exact nature of the patient’s needs, the doctor may over-prescribe to cover all eventualities. Kenneth also referred to over-consumption of medicines due to unregulated sales by unlicensed drug sellers.
As the BMJ proposes – and HIFA members agree – 'public awareness and education campaigns are needed to challenge beliefs that in healthcare “more is better” and to promote a more healthy scepticism about the benefits and potential harms of early diagnosis.” To realise this, there is a need to meet the medicines information needs of both prescribers and users of medicines. Healthcare providers and dispensing pharmacists have a responsibility to explain to patients how and when medication is to be taken.
During October, HIFA members also received fresh insights from the United Kingdom and the United States about the current and future implications of over-prescribing and over-diagnosis. In the US, the rapid increase in usage of opioid drugs since the 1990s has resulted in widespread addiction across the country, a consequence, says former US President Bill Clinton, of over-prescription. In 2015, 33,000 US citizens died from the effects of addiction. In the UK, Chief Medical Officer, Professor Dame Sally Davies foresees an even darker future for the world if prescription and usage of antibiotics, in particular, is not brought under control. She warns that, if ignored, antimicrobial resistance could spell “the end of modern medicine”, rendering routine surgical interventions such as hip replacements and Caesarean sections as highly dangerous. If we continue to prescribe Too Much Medicine based upon Too Little Information, it has been estimated that drug-resistant infections will kill 10 million people a year by 2050.
Metrics: In October, we exchanged 283 messages from 102 members in 33 countries (Angola, Australia, Bangladesh, Belgium, Burkina Faso, Canada, DR Congo, Ethiopia, Germany, Honduras, India, Jordan, Kenya, Lebanon, Mali, Mozambique, Nepal, Netherlands, Niger, Nigeria, Norway, Pakistan, Rwanda, Singapore, South Africa, Switzerland, Syria, Tanzania, Uganda, UK, United Arab Emirates, USA, Zambia). Our super-contributors this month were Chris Zielinski (UK-8), Andre Shongo (DR Congo-6), Isabelle Wachsmuth (Switzerland-6), and Joseph Ana (Nigeria-6). Thank you all for sharing your views and your experience.
Martin Carroll was previously Head of the International Department at the British Medical Association, London UK, and has worked on issues affecting health in LMICs since 2003. He represented the BMA on the HIFA Steering Group from 2008-16 and is now an independent adviser to the group. Martin is a member of two HIFA working groups - Multilingualism and Evaluating Impact of Healthcare Information - and the HIFA Social Media Working Group.