It's time to radically change the way we deliver and seek healthcare.
There are many reasons that healthcare systems continue to grow to provide more and more diagnostic options and treatment interventions, and why health costs are soaring. Moral obligations can be such that we feel a duty to help the sick in whatever way possible. In most cultures, death and disease are seen as an enemy that we must delay or overcome at all costs (physical, mental, spiritual, financial, or otherwise).
Now, our idea of health is transforming into something other than 'the absence of illness.' The process of achieving health is also transitioning toward a patient-centred, evidence-informed model, the foundation of a Less is More approach. Why? Consider it from multiple perspectives: those of the patient and supports, the responsible healthcare provider, and the government or population at large.
Respecting the Wishes of Patients+ show/hide
When healthcare teams have discussions with patients about 'next steps,' we often face a disconnect in expectations. Sometimes, patients want everything done while doctors see futility in proceeding. In other cases, doctors feel an obligation to pursue something aggressively, while a patient really would rather we 'leave it be.' Advanced Directives are helping patients better direct their care with an emphasis on their goals for living (and dying).
If bad things happen we seek hope. Sometimes it comes in the form of new drugs, new imaging technologies, experimental surgeries, alternative medicines, or second opinions. Many of us are also afraid of the unknown, so sometimes we want more information "just to see."
For example: A patient with back pain requests a CT scan of their spine. The physician advises that a CT scan is unnecessary given that there are no neurological findings on the clinical exam, and that the treatment plan will remain the same (pain control, weight loss, physiotherapy, avoiding re-injury) regardless of what the scan shows, since the pain is musculoskeletal in origin. The patient insists on the scan, despite being informed of the risks of radiation and the fact that it will not help them to get better faster.
Unfortunately the pursuit of an answer or ultimate solution is not always without risk. Each x-ray or CT scan bears the risks of radiation — higher rates of infertility and cancer — and imaging studies may often lead to unnecessary interventions, like surgery, which bear their own risks.
Patient-Centred Care and Shared Decision Making+ show/hide
More and more physicians are focusing on the goals of the patient, and patients are getting better at advocating for and participating in their health so that their wishes are respected. A 94 year old who has suffered a major stroke, compared with a 25 year old athlete who broke her ankle, probably has quite a different idea of what things she might like done in order to enhance her Quality of Life. A patient-centred approach is really the only way to help people achieve their definition of health.
When unnecessary tests or treatments are employed, they have very real harms. Examples may be helpful to illustrate this statement. There might be complications with a test if it is in any way invasive: reaction to CT-scan die, cardiac arrythmias from an angiogram, or bleeding and pain from a biopsy. It might waste someone's time, disrupt their routine, or create worry: fasting for 12hrs, traveling to the lab or hospital for a test, waiting for the results of a cancer screening test. A medication might have side effects: diarrhea (colchicine), headache (tamsulosin), or bruising (blood thinners). Or it might cause permanent damage: liver failure (statins), pulmonary fibrosis (nitrofurantoin). A bad reaction to a drug might kill a person: anaphylaxis (from allergy), Stevens-Johnson (many anti-seizure drugs), St. Johns's Wort (through interaction with anti-rejection medications in transplant patients).
The emphasis of the Less is More (aka "Right Care" or "Minimally Disruptive Medicine") movement is on finding the most suitable health plan for each person based on their life situation and what is important to them. While engaging in shared decision making, doctors and patients work together to make the individualized care decisions, keeping in mind that some interventions and tests may help with a patient's ability to achieve their health and personal goals, while others may hinder them.
Overcoming Defensive Medicine+ show/hide
Some doctors are afraid of missing something, getting sued, or having complaints filed against them if they don't make every option available to a patient. The resulting "defensive medicine" means that many extraneous tests and treatments are ordered, with insufficient regard for the consequences (health, financial, or otherwise) to the person or the system.
For example: A patient with a cough, runny nose, and a sore throat visits the doctor's office. The physician examines the patient, writes a prescription for an antibiotic, and sends the patient home.
Although we are turning the tide, it is still common for physicians to prescribe antibiotics for infections that are quite likely viral. This is worrisome because the consequences of antibiotic overuse include antibiotic resistant organisms (AROs), increased cost to the patient or insurance for the pills, and the risk of the patient experiencing side effects or developing complications like a yeast infection or C. difficile from the unnecessary treatment.
Incorporating Evidence+ show/hide
Note carefully that as we talk about more responsible medicine, we're not talking about stopping treatments that are appropriate for the disease and the patient and have good evidence behind them.
We use Evidence-Based Medicine (EBM) and related guidelines to help guide our selection of tests and treatments. Although advancements in technology and new medications are fascinating, very few of these developments have as positive an impact on health as we first anticipate. Also, a lot of medications and tests have not been studied for effectiveness, and even if they have, these studies may not be done on the patient population that we are treating; for example, a test for the effectiveness and safety of Aspirin in preventing stroke might show promising results in middle-aged males, but I have no way of knowing whether those same results will hold true for the elderly woman who is in my office asking about Aspirin today. Through rigorous study and broader analysis, we can learn which things work and for whom they work best. We can also discover more about the risks and benefits in order to help each patient determine what is best for them.
Although a lot of tests and medications may be seen as excessive and unnecessary, there are also times where patients are not being offered everything they should be. For reasons of resource unavailability or lack of physician or patient knowledge, not everyone is getting all the care they need.
For example: Jim lives in a small town in northern BC. His dad had bowel cancer, diagnosed at age 58. Since he is at higher risk, Jim should have a screening colonoscopy in order to make sure he doesn't have the beginnings of bowel cancer. Jim doesn't have a regular GP, so no doctor has ever really asked his family history, and Jim would never think to mention it when he's in for a refill of his blood pressure meds. Plus, he's heard there is a really long wait list for colonoscopy anyway, and he might have to go to a different town to have the procedure.
Bob, on the other hand, has no risk factors for bowel cancer, nor does he have any symptoms that would suggest it. He asks his doctor for a colonoscopy "just to check" and a referral is put in. Provincial guidelines suggest he should have had a stool test first, and proceeded to colonoscopy if that was positive, but he insists on a colonoscopy. The colonoscopy is done in 18 months and some benign polyps are removed. He gets a colonoscopy every 10 years. On the 3rd time, he suffers a complication of bowel perforation and requires a hospitalization with surgery and two weeks of IV antibiotics. He didn't know that approximately 5/1,000 people will have a serious complication from colonoscopy. (stat from BC Cancer Agency Colon Cancer Screening Program).
When there is suboptimal care we need to encourage uptake of good, right care. By avoiding unnecessary care, we can help avoid complications and devote our time and resources to making sure everyone is receiving what they should be for an excellent standard of care.
No question, cost is a taboo subject in health. No one ever wants to talk about cutting costs, because in so doing we may be seen as depriving patients of their right to the best care possible. I can say that 'Although there may be some cost savings to the patient or system when avoiding an unnecessary test or treatment, this is never the primary objective of making decisions in health care,' and I can feel good about it.
Although it may be politically correct to ignore the fact that we can no longer afford the kind of care we are delivering, it is not safe for society to do so any longer.
Of course thinking about sustainable, accountable, and sensible medicine is not new. However, except in specific contexts, there has never been a sense of great urgency propelling this style of practice forward. Terms like "sustainability" were very prominent in Global Health circles before they became frequently used in developed-world healthcare systems. It is because of the limited resources in undeveloped nations that global health practitioners have always had to think this way. But we feel that urgency more broadly now.
So, what has changed for developed-world healthcare systems like those in North America? We are finally coming to realize that we do not have unlimited resources. It is time to minimize waste in healthcare so that we can continue to provide a high standard of care.
We know that preventative health, including altering the social determinants of health (such as poverty), is one of the most affordable and effective way to improve health for everyone. However, it's hard to convince governments to invest up front, due to the realities of the political cycle.
In the grand scheme of things, 'Less is More' Medicine will allow us to provide better care. It will be better for the patients now, and for those in the future. Some hope that we can use the money, saved by a more judicious approach, to fund stable housing, nutrition, and health education and literacy, thus empowering even the most marginalized patient to achieve the best health possible. That might be a wonderful side effect of achieving our goal of delivering the best, patient-centred, evidence-informed care possible. This movement is not just advocating for less unnecessary care, but also for more of the essential care that is being missed.
Consistent with the IHI's Triple Aim, a "Less is More" approach will mean better quality of care from the patient perspective, a healthier population, and, subsequently, decreased costs of care.