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Paul Glasziou: Santa, could you take some things away instead?

20 Dec, 12 | by BMJ

Dear Santa,

This year, instead of presents I wondered if instead you might take some things away?

Maybe you could start with unnecessary tests, unhelpful diagnoses, and over treatment? These can be harmful to the individuals who receive them, but also results in patients with real medical needs having delayed or no services. If we could pare back to things with a demonstrable overall benefit, both groups would be better off.

I am not sure how long the Christmas wish list of an adult is allowed to be, but let me start with diagnoses—could we have a few less please?

Every variation from an ideal “normal” seems to have become a disease. For example, the prevalence of “abnormalities” of the knee joint on MRI in older people without knee pain is 86-88%, just a little lower than the 90-97% for those with pain. Improvements in imaging are creating new abnormalities and “incidentalomas,” which we don’t know whether to treat or ignore. But that is small beer compared to most of us being reclassified as having a “mental illnesses.” The DSM-V is set to increase that by changes to the definition of depression (no more grief please) and new categories such as minor neurocognitive disorder and disruptive mood dysregulation disorder. Allen Frances, former chair of the DSM-IV panel, has set out some advice for protection against what he sees as the 10 worst changes.

Then there is the over enthusiasm to detect everything early—but that can lead to over detection without compensatory benefits. As Muir Gray said: “All screening programmes do harm; some also do good.” Many seemingly sensible screening tests have been evaluated and found wanting—if you want to read about the sorry history and why, a good free source is: www.testingtreatments.org/tt-main-text/earlier-is-not-necessarily-better/ The problems of inappropriate screening have lead to group of doctors concerned about the safety and the ethics of private screening tests to develop some guidance and a compilation of advertisements. I also have quite a list of treatments—is there an address at the North Pole I can send a truck of evidence to?

You might have a look at vertebroplasty, arthroscopic knee lavage, cough medicines, neuraminidase inhibitors, multivitamins and a long list of “alternative medicines.” And then there is an even larger list of treatments that, though wonderful for specific groups of patients, are applied to other patients where they are unhelpful or even dangerous. Antibiotics are high on this list—if we could stop our addiction to overusing them, the rapidly developing population resistance could be halted and even reversed!

Oh, and finally there is all the new research that will be coming out and I won’t have time to read. Can you omit this from my stocking? Maybe instead you could send us all the unpublished research?

Let’s do a back of the envelope calculation. There are around 20 million articles in Medline, and about half of all research goes unpublished in journals, so that should mean there are around 20 million unpublished research articles (at cost of probably $100′s billions). That will take some time to sort out, so maybe you could include some funding for systematic reviews and reviewers to sift through that? No doubt, with all the negative unpublished studies we will have some more ineffective practices for you to take away next year.

Meanwhile, Merry Christmas and a Happy New Year.

Paul Glasziou is professor of evidence based medicine at Bond University and a part-time general practitioner.

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