Better Medicine

Shared decisions, best evidence

This Better Medicine resource page builds on the work of The BMJ's Too Much Medicine initiative and the overdiagnosis group of the RCGP in helping health professionals worldwide to share knowledge with patients and jointly make better informed choices about their care. It promotes better understanding of evidence-based options, dialogue about uncertainties, and critical debate about low-value interventions. It encourages the better communication of knowledge and seeks new methods to make this possible in every clinical encounter and in the public understanding of health issues.

About the RCGP overdiagnosis group

The RCGP group, led by GPs Margaret McCartney and Julian Treadwell (chair and vice-chair respectively), will use this online resource to:

• Help GPs and patients make shared decisions in consultations;
• Highlight evidence-based tools for use alongside existing guidelines; and
• Publish blog posts to deal with the practical and philosophical considerations connected with shared decision making and overdiagnosis.

The group defines "too much medicine" as "the idea that the diagnosis of some medical conditions may be unlikely to offer benefit to an individual in improved quality of quantity of life, and may also cause harm.

"This occurs where there is a low probability that the diagnosis, its treatment, or treatment of risk factors for the disease will improve outcomes important to a patient. Expanded disease definitions can mean that treatment is offered at lower thresholds, but this reduces the potential overall benefit."

This article by Margaret and Julian in the British Jourrnal of General Practice calls for a grassroots revolution among generalists to tackle overdiagnosis and overtreatment.

Overdiagnosis and general practice

Overdiagnosis and overtreatment are close to the hearts of many GPs. The desire to "do no harm" goes back to ancient times but is more relevant than ever in the complex world of modern medicine. Guidelines usually describe the evidence for single conditions, but in general practice, multimorbidity is the norm, and individual patients' values and priorities may not always be the same as those of guideline creators. Trying to find the right path between too much and too little medicine can be very difficult, but sharing decisions with patients is key.

The online RCGP overdiagnosis group exists for anyone from patients and GPs, to other clinicians, pharmacists, nurses, and academics, who are interested in the debate around overdiagnosis and overtreatment.

Discussions are varied and fast moving; group members are often authors of the research evidence, guideline, article, or blog at the heart of some of these conversations. We hope eventually to make available a synthesis of some of these to share the knowledge and experience of group members with a wider audience. For information about joining the discussion group please email Margaret McCartney.

A criterion for joining the group is that a public declaration of interest is made; these declarations can be found at whopaysthisdoctor.org

Overdiagnosis blogs

• Selling statins to patients
• When is a disease not a disease?
• When does risk factor management lead to overdiagnosis?

Preventing Overdiagnosis conference

The BMJ is a partner in the international scientific conference, Preventing Overdiagnosis. The next conference is taking place on 17–19 August 2017 in Quebec City. Find out more by looking at our digital theme issue on overdiagnosis

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Watch highlights of the 2015 Preventing Overdiagnosis conference

The BMJ and overdiagnosis

In this editorial, Fiona Godlee, editor in chief of The BMJ, and overdiagnosis researcher Ray Moynihan, senior research fellow at Bond University, Australia, explain more about the campaign.

Godlee said: "Like the evidence based medicine and quality and safety movements of previous decades, combating excess is a contemporary manifestation of a much older desire to avoid doing harm when we try to help or heal.

"Making such efforts even more necessary are the growing concerns about escalating healthcare spending and the threats to health from climate change. Winding back unnecessary tests and treatments, unhelpful labels and diagnoses won’t only benefit those who directly avoid harm, it can also help us create a more sustainable future."

The BMJ's ongoing overdiagnosis series now includes more than 200 articles. The RCGP's overdiagnosis group has identified the following key articles from The BMJ:

• Winding back the harms of too much medicine
• Overdiagnosis: when good intentions meet vested interests—an essay by Iona Heath

Interactive timelines of relevant articles from The BMJ

Digital theme issue

A digital theme issue on overdiagnosis, published in March 2015, looks at what is too much medicine and who gets to decide? Although there is consensus that too much medicine is real and damaging, large uncertainties remain about where and how the lines between appropriate and inappropriate care should be drawn in any individual case. Find out more here.

Has modern medicine undermined the capacity of individuals and societies to cope with death, pain, and sickness? Has too much medicine become a threat to health? Yes, argued Ray Moynihan in a theme issue in April 2002. He accused the pharma industry of extending the boundaries of treatable disease to expand markets for new products. Barbara Mintzes blamed direct to consumer advertising of drugs in the US for portraying a dual message of "a pill for every ill," and "an ill for every pill." Elsewhere in the issue, doctors were accused of colluding in and encouraging medicalisation. Leonard Leibovici and Michel Lièvre wrote : "The bad things of life: old age, death, pain, and handicap are thrust on doctors to keep families and society from facing them."

Links to the Mayo clinic shared decision making national resource center

Depression medication choice

Links to National Institute for Health and Care Excellence (NICE) patient decision aids

Taking a statin to reduce the risk of heart disease

Atrial fibrillation: reduce your risk of a stroke?

Useful links:

• Choosing Wisely
• Center for Medical Consumers - Why too much medicine is making us sicker and poorer
• Preventing Overdiagnosis conference
• Consumer Reports
• Avoiding Avoidable Care
• Selling Sickness
• Dartmouth Institute for Health and Clinical Practice
• Bond University

Disclaimer

The RCGP and The BMJ do not monitor the content of third party websites. Any link provided is solely for your convenience. We do not control or accept any responsibility for any third party website or for any liability arising from its use. Access to and use of any third party website is carried out solely at your own risk.