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Over-medicalisation: dealing with a modern problem

by
01 November 2015, at 12:00am

THE MERCURY COLUMN in which a guest columnist takes the temperature of the profession – and the world around

MAYBE it’s a consequence of greater availability of information, or the limitless accessibility of that information without the caveats and qualification of informed context, but health services around the globe have seen the inexorable rise of medicalisation.

One definition of “medicalisation” would be where consumers seek medical treatment for lifestyle problems although another might be that, for some, morbidity and mortality represent a failure of the system.

This has been increasingly referred to as over-medicalisation and, although some authors see this an unnecessary exaggeration of an already undesirable consequence of western medicine, there is no doubt that institutional intervention has played a major part in changing public perception about what is “normal”.

Those charged with containing the burgeoning costs of the NHS would cite the “normalisation” of increased use of medicines, unwarranted medical tests, rising hospitalisation rates and unnecessary but now routine interventions such as caesarean sections and other surgical procedures, all of which are potentially life-threatening, as contributing one of the greatest threats to the sustainability of our national healthcare model.

As autumn dissolves into winter, the inevitable spectre of swamped GP surgeries and emergency departments will catapult the issue back into the headlines. Of course, this will become a political football once again with little regard for some of the root causes which may not be as straightforward as one thinks.

A national healthcare model will always be dependent upon the availability of the army of medical staff which it employs and medical interventions based on political or financial expediency are hardly new.

As an example, 40 years ago when my eldest son was born, they were wheeling out the oxytocin drip to ensure that he was delivered on a Friday and not on a more staffdependent, high-cost weekend.

However, in today’s world of obstetrics, the data clearly show that the safest place to have a “normal” delivery is at home. There are multiple factors at play, including concerns over litigation, but the medicalisation of childbirth through what is now routine medical intervention clearly adds a series of risks which would not be encountered in a home delivery.

I readily accept that any such data cannot be viewed in isolation and who am I to define what is “normal”?

Indeed, even cultural norms vary enormously and anecdotal accounts from those who are active in providing care will tell you that many Eastern European women display a highly resilient and determined approach to the challenges of returning to the real world immediately after childbirth and, in many cases, in dealing with “normal” activities such as breast feeding.

Societal change does not always do itself any favours and, while every scientist knows that maternal milk provides a host of early benefits for both the infant and mother, today’s generation of mothers need considerable encouragement to attempt and persevere with breast feeding. This may not have been the case even 100 years ago when artificial alternatives were unavailable. Again, multiple factors are at play here but just seven years ago, fewer women in England began breast feeding their baby than in almost any other European country. Much has been done to counter that statistic, more recently, but the World Health Organization data bank reports on breast feeding make fascinating reading.

Of course there is “bad medicine” where adverse results emanate from unnecessary treatment, e.g. polypharmacy in the elderly, which leads to several thousand elderly admissions every year in the UK due to adverse drug reactions, or the societal factors that have led to the overuse and abuse of antibiotics – making this perhaps the most critical public health issue of our time.

Questionable practices

Additionally, there is the spiralling use of antidepressants and sedatives, and the questionable focus on the preventive role of cholesterol in heart attacks.

Well over half the people having their first heart attack have normal cholesterol levels and World Health Organization data show that 80% of cardiovascular disease is caused by smoking, inactivity, unhealthy diet and other lifestyle factors.

The public largely believes that the widespread use of statins will drastically reduce cardiovascular challenges and an estimated 12 million people in the UK will be prescribed a statin for routine, lifelong use. While medical scientists are divided over the value of statins, many who use antihypertensives to control a level of mild to moderate hypertension, together with a statin, have abandoned other lifestyle measures to aid cardiovascular health in the mistaken belief that their preventive medication has completely addressed the issue on their behalf.

The same can be said for obesity which may yet turn out to be a contributing factor to an uncontrollable wave of diabetes – while there are a myriad of drugs available to help manage this epidemic, simple lifestyle changes provide a more effective and longer lasting approach.

The problem is not that people cannot change their lifestyle to accommodate this need; society has been allowed to believe that common aliments, whether self-induced or not, are a disease and that the universal goal is to eradicate disease.

All too often the common belief is that disease should be eradicated for us and not by making long-term alterations to our lifestyle.

An uphill battle

Clearly, the politicians and the medical profession have an uphill battle on their hands and, while the medicalisation of healthcare may have helped patients engage with their condition and seek to better understand it, it provides little benefit if it prevents them from making longterm alterations to their lifestyle or approach to their individual situation.

How much better it might be if we could encourage more patients to question whether they really need a certain test or procedure, what the risks might be, and what would happen if they waited longer or even did not carry out the procedure?

Such questions would indicate both an active engagement with the process and, more importantly, the adoption of self-determination in the relationship with one’s own health.

In an excellent article written in 2014, Dr Kailash Chand, deputy chair of the BMA council, stated that, in his personal opinion, “The doctor’s role is crucial in educating patients and treating them according to clinical need, not succumbing to inducements or medical, pharmaceutical and financial targets. Their goal must be to do as much more for the patient and as little as possible to the patient.”

In our veterinary profession, where many see productivity and the dynamics of practice performance as providing a measure of success, more discussion and sharing of experiences would add a welcome counterpoint.