In search of the things we do without reason

Nacho Vallejo

In healthcare, there is usually a special appreciation for tradition or antiquity, which does not always translate into better clinical care. The reality is that there are things that we professionals do without the contrast of adequate evidence or, simply, without these actions providing sufficient value.

The Choosing Wisely initiative was launched a few years ago from a private North American institution. It was necessary to suggest to the scientific societies of that country the development of recommendations on clinical practices that both doctors and patients should rethink.

Despite the progressive development of the lines of work and the extension to other countries, the impact on our practise didn't benefit from the needed consideration to reduce waste maybe because the routines are very established. It is difficult to swim against the current, or perhaps due to the practice of defensive medicine or, even, to avoid suspicions of being collaborative in the cuts.

Abraar Karan is a resident of Internal Medicine at Brigham and Women's Hospital and Harvard Medical School. Being a regular columnist for The British Medical Journal is one of his many curricular activities. Karan, in a recent  magazine  publication, reflected on how, in hospitals, we do things simply because "this is how we have always done them."

On one occasion, during the usual rounds of the plant pass, he reflected with his team on the real need to maintain monitoring of vital signs, particularly at night. The patient was stable; oxygenation did not raise any cause for worry, nor was the heart rate. Telemetry, oxygenation probe, measurement of blood pressure every four hours, incessant work of the night team during the care of a newly hospitalised patient had led him to complain about the impossibility of resting in the hospital. 

Many of these patterns, as is also the case for analytical extractions, are established routinely without reason (test or clinical trial) that justifies them, in what the author of the text sets as "predetermined effect" - a term related to behavioural economics. Essentially, it suggests that an individual will choose the “default” option unless the cost of switching to a different option is less than the cost associated with maintaining that value.

To facilitate an operational change, the author justifies the need to incorporate different habits into our hospitals. First of all, it is writing down an "unnecessary things" checklists: daily analytical extractions, constant monitoring, testing for blood glucose, the indication of prevention of deep vein thrombosis, diet restrictions or even immobilisation in bed.

Systematically questioning our practices comes as a second priority. What data is behind the reasons why we are doing things the way we do? If there is no evidence, what is the reason for perpetuating it? Are we aware of what it can mean in terms of discomfort for our patients, unnecessary work for other professionals or even healthcare costs?

Finally, we must consider the negative consequences that we may unintentionally cause to our patients. Many extractions can lead to iatrogenic anaemia. Unnecessary monitoring leads to a bad night rest. Restrictive diets worsen the nutritional situation of our patients. The unjustified immobilisation has negative consequences of loss of functionality and worsening fragility of older patients.

Unnecessary testing and treatment is a widespread problem and is present in practically all hospitals, regardless of their size or the dedication of their professionals. A 2017 report from Canada's Institute for Health Information and Canada's Choosing Wisely initiative identified that up to 30% of tests and treatments might be potentially unnecessary in this area.

Knowing the magnitude of the problem and its repercussions, particularly on patients, should be a starting point for incorporating this reflection into the analysis of the situation and evaluating this reality in our centres.