Monday, 4 August 2014

The parsimonious medicine

I started the last Mondays’ post with the "Too much medicine" campaign from the British Medical Journal but in this one I want to talk about the "Less is more" article from "JAMA Internal Medicine" that began in April 2010 with the aim of bringing to our attention the side effects of diagnostic tests and treatments that from the outset are not expected to add any value.

Parsimonious medicine versus spending cuts

Dr. Jon Tilburt, an internist and researcher in biomedical ethics at the Mayo Clinic, and Dr. Christine Cassel, president of ABIM Foundation (see the Video that presents the "Choosing Wisely” campaign), in an article published in JAMA, attempt to differentiate between the ethics of "no budget and therefore I can’t request a test" and those of "this test does not suit you, it will not contribute anything new to what we already know, and additionally, the test itself carries risks that do not outweigh the expected benefits". According to the authors, as at the moment the two ethics are competing on the same stage, an effort must be made to explain them better from a professional point of view. 

The parsimonious medicine promotes starting clinical performances with basic testing and treatment, calibrating the intensity of the process to the complexity of the illness and with the patient’s point of view. The recipe is simple: clinical reasoning, differential diagnosis, asking what each required test will bring back, using time as an ally, tolerating and sharing the uncertainties of the process itself and easing of the patient’s worries with the strength of the trust.

The evidence-based persuasion. An ethical imperative

Also in JAMA, another article was published by two authors of the Institute of Biomedical Ethics at the University of Basilea in Switzerland. In the context of introducing some wisdom into clinical activities from professionalism, the article proposes the use of persuasion as an essential tool, and focus on the following 6 points:
  1. Combating patients’ prejudices
  2. Honestly report on evidence, improvements and risks
  3. Provide personal opinion if required
  4. Preferring reasoning to emotions
  5. Avoid creating new prejudices
  6. Be receptive to patient’s preferences
This seems an obvious recipe as often happens with authentic things, and many will say, “that's what I always do in my practice”, but be honest: are you sure?


Budgetary restrictions are here to stay, at least for the long term. For this reason and after presenting the campaigns “Too much medicine" by the BMJ and "Less is more" by JAMA, I propose reflecting on whether, from the professional perspective, if we battle waste with clinical judgment, we can maybe achieve adhering to budget without affecting the quality of care, or even improving it.


Tilburt J, Cassel C. Why the Ethics of Parsimonious Medicine is not the Ethics of Rationing. JAMA February 27, 2013; 309(8):773-4.
Shaw D, Elger B. Evidence-Based Persuasion. JAMA April 24, 2013; 309(16):1689-90.

Jordi Varela


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