Q&A: New podcast offers ways to reduce medical excess that harms patients, the planet

The BMJ and Cochrane Sustainable Healthcare have jointly launched The Recovery, a new podcast highlighting initiatives that practitioners around the world are using to reduce medical excess.

Medical excess causes harm to patients, health care systems, societies and the planet, according to Minna Johansson, PhD, the director of Cochrane Sustainable Healthcare and a general practitioner in Sweden, Fiona Godlee, MD, the editor in chief of The BMJ, and Ray Moynihan, PhD, an assistant professor at the Institute for Evidence-Based Healthcare at Bond University in Australia.

“It is estimated that a fifth of what we do in health care is not needed,” they wrote in an opinion piece in The BMJ. “All those unnecessary tests, treatments and diagnoses bring direct harm to people through adverse effects of drugs and surgeries, psychosocial harms of labeling and increasing the burden of treatments. Since resources for health care are finite, waste is also harming patients indirectly because the overuse of some medical interventions means there are fewer resources to tackle underuse and underdiagnosis in other areas.”

Godlee and Moynihan cohost the six-episode podcast series and interview physicians about “new, and sometimes radical, initiatives” to make health care more sustainable, according to a press release.

Healio Primary Care spoke with Johansson to learn more about medical excess and how it contributes to medical waste, burnout and patient harm.

Healio Primary Care: What is medical excess and in what ways is the health care system unsustainable?

Johansson: I have been working as a general practitioner for about 10 years. It has been very clear to me that the way we practice medicine today is unsustainable. It is helpful to understand medical excess from the perspective of sustainability. We need to reform the way we think about resource use and can learn from the environmental movement with climate change. There is something fundamentally problematic with how we understand resources within medicine today, both in terms of human resources, the time of patients, financial resources and ecological resources.

Studies have shown that many patients report feeling overwhelmed and that the treatment burden on patients with chronic conditions is huge. When patients don’t have the resources or the ability to do everything we press upon them, we call them noncompliant, while in reality, it’s actually our demands that are extremely high. That is unsustainable for patients. Many patients undergo unnecessary surgeries or other treatments that cause them harm with limited benefit. In the U.S., it’s not sustainable financially for many patients.

On the clinician level, there’s a massive gap between what is being recommended in the guidelines and policy documents and the available resources to do them. There are many studies that show this; it’s impossible to follow all of the guidelines. Being at the forefront of medicine can feel like taking a tsunami of these recommendations on what to do and only being able to follow a tiny fraction of them. That leads to burnout among many physicians.

On the societal level, all around the world, health care is consuming a larger and larger proportion of societal budgets. This can be questioned from a public health perspective because health care is estimated to be able to affect only about 10% of all avoidable premature death; the other 90% is societal health care or interventions and societal structures. They are the factors that affect the health and well-being of the population to a much larger degree. But we have this development that health care takes more and more resources from societies, and this is probably not good for public health.

Healio Primary Care: How has the pandemic highlighted this medical excess?

Johansson: The pandemic has had brutal consequences, and I have seen that firsthand. Many of my patients have been severely ill from COVID-19, and some of them have died. I’m not saying that has been good in any way, but during the first wave, we started to understand that we need to reduce medical excess. We need to stop doing lots of unnecessary checks, referrals, etc., because patients could be harmed when they go to the hospital. The public suddenly understood that the hospital is not a resource to take lightly, and it could be a dangerous place for people. That’s true even before the pandemic but people didn’t think about it like that. We have the kind of culture where we think it’s always good to do more. But suddenly, almost overnight, people started to understand that this is something that we should avoid, and it could actually harm you to do more. The other thing that was really clear to me was that suddenly, with all the policies that direct exactly what all clinicians should do, we were allowed to break those rules. Our professional judgment was once again trusted. We became much more aware that there are potential benefits and harms from doing this or that. This atmosphere of defensive medicine took massive steps back in the beginning of the pandemic. I think in that sense, the pandemic was in some ways good. Many people avoided unnecessary treatment or testing, but of course, many people also didn’t get the medical interventions that would have provided a benefit. I think we can learn something from it.

Healio Primary Care: Do you think the institutions that draft new policies and recommendations consider how they may contribute to medical excess or patient burden?

Johansson: In general, it’s not very well done. That depends on very many factors. It would be naive to ignore that there’s a lot of vested interests in medical excess. There’s huge money to make and this affects how it’s done. Also, medical science has been focused on primarily the benefits of medical interventions. and evidence in guidelines focuses on that. Traditionally, we have been very poor at looking at harms, and we miss a lot of harms that are very important for the patient but perhaps more difficult to measure. Even in high-resource settings, when following only the evidence-based guidelines on hypertension, for example, it would take all the time general practitioners have and they would not have time to do anything else. There are other studies that show the same thing for different conditions. The guidelines are poor at considering medical excess. The evidence is poor at considering medical excess. Primary research and policymakers are poor at it.

Healio Primary Care: Do you have any suggestions for how physicians can make their practice more sustainable?

Johansson: There are so many things. It’s our intention in the podcast to be really concrete about what people do, and we try to talk about that in every episode. I think people can feel inspired because that question relates to where you are. Maybe the situation is very different at your practice or in your country. As a general practitioner, I can take a step back and be brave about not letting, for example, the fear of getting sued drive how I practice medicine. Try to take time for unhurried conversations with patients. Listen to what they say and be focused on the patient in front of you so that patients who need it most get the most access. I think there’s a lot of things that we can do in that way. Of course, with the emerging fields concerning the carbon footprint from health care, there’s going to be an explosion of evidence on what interventions take the most energy or are most harmful for the planet and which interventions should be avoided. But we work in a very industrialized system and it’s very difficult to change something. But as Victor Montori, MD, a professor of medicine at the Mayo Clinic, said in our podcast, in 100 years or so it will be very difficult to know if something we did now made a change or not. We should think about it as a painting; we can’t paint the whole painting, but we can decide which stroke we want to put on the painting. It’s important not to give up just because it’s so difficult and complex. Everyone needs to do their part. The whole reason I started covering health care excess and doing the podcast is because I feel that it would be so much better for my patients. And that’s what’s driving a lot of us. We need to change medicine. I think we can do it, but it takes effort.

References:

Cochrane Sustainable Healthcare. Podcast — The Recovery. https://sustainablehealthcare.cochrane.org/podcast-recovery. Accessed Nov. 22, 2021.

Johansson M, et al. BMJ. 2021;doi:10.1152/ajpendo.00599.2020.

The BMJ. Podcasts. https://www.bmj.com/podcasts. Accessed Nov. 22, 2021.