Health

Is a growing tendency to overprescribe tests and treatments turning the elderly into ‘professional patients’? By Ray Moynihan.

Over-medicalisation: doing more harm than good

Bone densitometry tests may be being overused.
Credit: BSIP / UIG VIA GETTY IMAGES

A few months ago a bed-bound woman in her early 80s was admitted to an Australian hospital. Someone’s mother, grandmother, sister or aunt. Extreme immobility had caused blood clots and pneumonia. On admission she appeared to be hallucinating, agitated and unco-operative, throwing glasses of water at medical staff. 

A review discovered that among the woman’s medications were an anti-anxiety pill and an anti-depressant as well as two powerful anti-psychotic drugs. Her doctors decided she did not have a major psychotic illness and the mind-altering medications were withdrawn. She soon became calm and co-operative, and according to a confidential account of the case, “the real lady blossomed”. 

Medicine can extend life and reduce suffering, but there’s little doubt many of us are now getting too much of a good thing – and too many people are turned into patients unnecessarily. 

It’s 40 years since the radical cleric Ivan Illich described how common ailments were being transformed into medical conditions, causing the “medicalisation of life”. Maligned by many and dismissed as quixotic, Illich today appears more prescient and prophetic than ever when he argued: “The medical establishment has become a major threat to health.”

Asked about the case of the elderly woman, geriatrician Dr David Le Couteur says it’s an all-too-familiar drug-induced delirium, and a good example where withdrawing unnecessary medicines can be helpful. A professor at the University of Sydney and a specialist at Sydney’s Concord hospital, Le Couteur is alarmed at what he sees as the over-medicalisation of ageing. Together with colleagues, he spends his days on the hospital wards trying to wind it back.

“We undiagnose, we withdraw treatment, and we de-prescribe – and people improve,” Le Couteur says enthusiastically. “We do it not to reduce cost. We do it to improve quality and quantity of life.” 

The clumsy-sounding new parlance of “undiagnose” and “de-prescribe” perhaps reflects how antithetical this new thinking is to well-established norms of practice.

Asked for examples of conditions he might undiagnose in an older person, Le Couteur points to dementia and mild cognitive impairment, high blood pressure, diabetes and the bone condition osteoporosis, where labels and subsequent treatments in many cases can do elderly people more harm than good. “These are diagnoses we undo,” he says. 

Dr Karen Hitchcock, a specialist in acute and general medicine in Melbourne’s Alfred hospital agrees many elderly are on far too many medications. “I spend way more time crossing off medications than adding them,” she says. 

Hitchcock, a columnist for The Monthly, argues that over-medicalisation happens across the entire life span, in part because we make social problems into medical ones. She uses obesity as an example of a problem we look to doctors to fix, rather than taxing junk food, subsidising fresh food, or building infrastructure that encourages people to move more. “We seem to value high-tech medicine and the industries that make it, while neglecting the social determinants of health and disease,” Hitchcock says. 

Doctors such as Le Couteur and Hitchcock are no longer alone. The highly influential British Medical Journal has a major international campaign under way called “Too Much Medicine”. Here there’s now an official Australian Deprescribing Network of doctors and researchers, rigorously studying how to safely withdraw medications and, sometimes, the diagnostic labels that go with them. And the federal government is also taking a strong interest, with a major review under way of all tests and treatments covered by Medicare to try to work out what works well and what might be doing more harm than good. 

Announced in April and given a publicity boost last weekend, the official government review is extremely wide-ranging, with specific committees being set up in almost all areas of medicine, from allergies to mental health, neurology to urology. 

There’s a much shorter list of priority areas that are being reviewed first – tests and treatments where there’s already concern about the possibility of overuse. Along with some better-known examples of too much medicine, such as scanning and operating on the knee, there are some surprises, too.

The review committee looking at diagnostic imaging is investigating the aggressively promoted “bone densitometry” tests used to diagnose osteoporosis. Private for-profit companies are currently touring the country spruiking these tests and even pharmacies are offering quick scans to check your bone density.

The problem here is growing concern that many healthy older women are being over-diagnosed with osteoporosis – in other words, being tested then labelled then treated, when in fact their condition would never cause them any undue harm. Osteoporosis is more properly considered a risk factor rather than a disease, where the risk is of a future fracture, and many of the women diagnosed with it will never experience one. Making matters worse, the scans are not as reliable as one might think, and the level of bone density is not a great predictor of future fractures. 

For some people at high risk of fracture, a diagnosis of osteoporosis and drugs to treat it may well help to meaningfully reduce that risk. For those at low risk, the label and the treatment may be unnecessary and even potentially harmful, given the side effects of common medications, including gastrointestinal problems and in extremely rare cases dead jaw syndrome. 

Another of the government’s priority reviews is looking at the way we manage the condition called pulmonary embolism, a blockage in the artery of the lungs. Like osteoporosis, this is another condition where there’s concern many people at very low risk of illness are being over-diagnosed and over-treated. In the past big blood clots were killers and treatment could be hugely beneficial. But with modern sophisticated scanners such as CT machines, much smaller clots are being diagnosed and treated, including many believed to be totally benign. 

“Everywhere you look, there’s waste,” says Dr Norman Swan, the veteran ABC health broadcaster. Swan presented a special Four Corners investigation on Monday night, with staggering estimates that perhaps a third of all the $150 billion yearly health expenditure is wasted. “We need a much more honest conversation between doctors and patients,” he says. 

The program covered examples including over-testing of knee pain, back pain and chest pain, suggesting unnecessary tests and treatments may sometimes be taking place more often in the private sector where specialists can profit. 

While Swan doesn’t think commerce is the only driver of excess, and he suggests corporate players may have a constructive role to play in fixing the problem, he does point to the big bucks now being made in Australian medicine. “We now have private equity moving into IVF, into radiology and pathology, we have companies being floated, and we have profits being dependent on the government purse.” 

For Swan, one of the key reforms needed is to move away from a fee-for-service system that rewards throughput, and towards a system that pays doctors for improvements in health outcomes. In such a system, a surgeon would be paid for performing an appropriate operation, not just any operation. 

Yet defining what’s an appropriate procedure or drug and what’s not – and who should be tested and treated and who shouldn’t – is not simple. The reality is there’s almost always a group of people who can benefit from any test or treatment – the number that are just plain useless or harmful is very, very small. The challenge is trying to restrict the use of medical interventions to those who’ll benefit. And that’s the highly complex task now being undertaken by all those committees of the federal government’s review. 

Le Couteur is encouraged by the review, but believes we need to work out how to de-medicalise and enable patients, particularly older ones, to become people again. “The over-medicalisation of ageing brings direct harms for the people involved,” he says, citing side effects of drugs as an example. “But the broader societal harm is that our seniors become almost like professional patients, busy with constant visits to doctors, hospitals and pathology labs, and their roles as grandparents, as leaders, as elders, become diminished.” 

Undoing diagnoses – whether it’s for yourself or a loved one – might sound daunting. And like all matters medical, there will be risks and benefits involved. But maybe it’s time to start using these awkward new words “undiagnosing” and “de-prescribing” a little more often.

This article was first published in the print edition of The Saturday Paper on Oct 3, 2015 as "Diagnosis excessive". Subscribe here.

Ray Moynihan
is an author and BMJ columnist, and a senior research fellow at Bond University.

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