The characteristics of health systems are complexity, uncertainty, opacity, poor measurement, variability in decision making, asymmetry of information, conflict of interest, and corruption. They are thus largely a black box and uncontrollable, said Gianfranco Domenighetti of the Università della Svizzera Italiana at a meeting in Bologna on La Sanità tra Ragione e passione (Health through reason and passion). The meeting was held to celebrate the life and work of Alessandro Liberati, the founder of the Italian Cochrane Centre, who died last year.
Only 11% of 3000 health interventions have good evidence to support them, said Domenighetti. A third of the activity in the US health system produces no benefit, said a recent study in the New England Journal of Medicine. Half of all angioplasties are unnecessary. Some €153m a day is lost through corruption in health systems in the European Union. Four fifths of new drugs are copies of old drugs. Screening is creating diseases like ductal carcinoma in situ. Most doctors (80-90%) have taken “bribes” from pharmaceutical companies, although many may not see their free pens and lunches and subsidised travel as bribes (but if they are not bribes what are they?). Between 15% and 40% of articles in medical journals are ghostwritten. Half of clinical trials are not published, and there is systematic bias towards positive results, hence suggesting that treatments, usually drugs, are more effective and safer than they actually are.
Yet against this backcloth more than four fifths of people in most countries think medicine is an “exact or almost exact science.” In a study published in the Annals of Internal Medicine nearly 90% of patients undergoing percutaneous coronary intervention (PCI) thought that it would reduce their chances of having a heart attack, when it doesn’t. Asked about various scenarios almost half of cardiologists questioned would go ahead with a PCI even when they believed there was no benefit to the patient.
It is time, said Domenighetti, to open up the black box of healthcare. Encouraging “health literacy” seems to be a way to do this, but Domenighetti thought that this was “old wine in new bottles.” We need, he said, to encourage a healthy skepticism about the medical market and to help people understand that medicine is far from being an exact science. Data should be published exposing variations in practice, corruption, and conflicts of interest. We should explain that health depends mostly on exogenous factors not the healthcare system. And people should be given practical tools to promote their autonomy—tools like access to evidence based information.
Domenghetti ended his talk by pointing people towards the Choosing Wisely campaign in the US where professional organisations are identifying interventions that offer little or no value. A similar but broader campaign of Slow Medicine is underway in Italy, and I have little doubt that slow medicine—like slow food and slow lovemaking—is the best kind of medicine for the 21st century.
We need to pull back from what Ivan Illich called the hubris of medicine.
Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.
Competing interest: RS spoke at the meeting and had his expenses paid by the health department of Emilia-Romagna.