Trevor Hancock: The secret of medicine is masterly inactivity

I was trained in medicine almost 50 years ago at a very old and traditional teaching hospital in London, England — Bart’s. It was an excellent training in which we were taught the art of medicine, with a scientific underpinning.

But the most important lesson I ever learned was from a professor of medicine who taught us “the secret of medicine is masterly inactivity.” The reason you go to medical school for six years, he told us, is to learn when it is time to stop doing nothing.

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There is enormous wisdom in those words, which I have never forgotten.

What he meant, of course, is that most things are minor and get better on their own, if left alone. The trick, of course, is to see when things are not minor, or are not getting better on their own, and then to intervene. My training also emphasized arriving at a diagnosis based on a good history and physical examination, not an over-reliance on tests.

This was particularly useful preparation for family practice: Two other things I learned in my family-medicine practice complemented his invaluable lesson: “watchful waiting” and “the tincture of time,” both of which refer to the same approach — wait and see.

So it was troubling to discover, when I arrived in Canada in 1975, that in North America medicine was less an art and more a science — and that is even more true today. In many ways, I think it a pity.

Here, the secret of medicine seemed to be to do a lot of tests and to intervene, and not always in masterful ways. The result is over-investigation and over-treatment, which has been and continues to be a major problem.

Choosing Wisely is a program that began in the U.S. in 2012; as the U.K. version of the program states, it was created “in part to challenge the idea that more is better or in the case of medical intervention: just because we can, doesn’t always mean we should.” More than 70 specialty societies in the U.S. have identified their “top five” tests and treatments that are overused and do not provide meaningful benefits for patients. The intent is to “spur conversation about what is appropriate and necessary treatment.”

Over-treatment is expensive and wasteful. In the U.S., Don Berwick — a physician and much-respected founder of the Institute for Healthcare Improvement — suggested in a 2012 article in the Journal of the American Medical Association that over-treatment cost the U.S. health-care system between $158 billion US and $226 billion in 2011. He also identified five other major forms of waste that between them cost a further $400 billion to $1.036 trillion; altogether, waste accounts for 21 to 47 per cent of all health-care spending.

In the U.K., the Academy of Medical Royal Colleges, which represents 22 specialist licensing colleges, recently reported that “across the U.K., there is a growing culture of overuse of medical intervention.” But as they also note, “the problem for patients is that all tests, procedures and interventions have side-effects and some may even cause harm.”

In fact, harm caused by health care has become a serious problem. A report last month from the Canadian Institute for Health Information identified 31 types of harm that can occur in hospital, and noted there are more types of harm that they did not measure. For those 31, they found that in 2014-2015 “patients suffered potentially preventable harm in … about one in 18 hospitalizations.” But harm also happens outside hospitals, and this was not measured.

In the U.S., Martin Makary, a professor of surgery at Johns Hopkins University, recently reported in the British Medical Journal that at least 250,000 Americans died in 2013 as a result of medical error, making it the third-largest cause of death after heart disease and cancer. And his team thought this was an underestimate, because they, too, looked only at deaths occurring in hospital and documented in medical records.

So it is time North American medicine took a big breath, stepped back and started to apply masterly inactivity in its practice. We would all be better off, and as an added bonus, our health-care costs would drop.

 

Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.

thancock@uvic.ca

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