Monday, 19 December 2016

Against medical overuse, more primary care

Atul Gawande, a surgeon and author of the book "The Checklist Manifesto" and "Being Mortal" among others, has published an article in The New Yorker, "Overkill," which talks about the disproportionate clinical practices, especially those in their country, the USA. It’s a long and well-documented writing that I’d like to comment on in this post for two aspects I consider important because they can help fight the epidemic of overdiagnosis and medical overuse. The first question posed by Dr. Gawande is an organizational consideration of diversion of resources, and the second is a proposal to avoid mistakes when prioritizing budgets.

Preventive activity and daily clinical work

The case-mix seen in clinics today has changed dramatically with the impact of secondary prevention programs and the medication of risk factors. Now the doctors’ agendas and especially those of family physicians are filled with healthy people who are afraid of getting sick, a situation that not only uses up medical time but also diagnostic tests, medications and referrals to specialists (if you are interested in this issue don’t miss the book "The patient paradox" written by the Scottish family physician Margaret McCartney). Cost considerations aside, health resources are so busy in offering care for healthy people and invest so little effort in addressing the clinical complexity of some patients that what they need really is multidisciplinary work and integration of services.

A successful proposal: more resources to primary care

The remedy for little value clinical practice is enhancing primary care, says Dr. Gawande in his article. Someone will think that I said so a long ago but don’t dismiss the fact that it’s now a surgeon who proposes it from the pages of the New Yorker. And this is important, because the idea of "more primary care, less specialists," as a way to meet the challenges of complex chronic and geriatric frailty, certainly very supported by evidence (see "Tracking Medicine" by John Wennberg and "Overtreated" Shannon Brownlee) moves only in very restricted areas of primary care, and in particular forums is seen as a corporate claim over the primary care. I think if we did a survey about where should we put more resources (personally I have not seen any yet), I am convinced that people would still find it difficult to decide, because leaving aside that they like to have a primary care unit nearby, most people don’t want to give up having access to technological medicine.

In short, two very timely reflections from two doctors: Gawande and McCartney: a) the overuse of medical prevention diverts resources and professional efforts towards practices of little value, while health systems are struggling to adequately address the most complex cases, especially those requiring integrated community services, and b) complex chronic patients must be maintained as far as possible from specialists and that means more primary care and more multidisciplinary teamwork.

Jordi Varela

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