Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine

The idea that somemedical procedures are unnecessary and can do more harm than good is as old as medicine itself. In Mesopotamia 38 centuries ago, Hammurabi proclaimed a law threatening overzealous surgeons with the loss of a hand or an eye. In 1915, at the height of a surgical vogue for prophylactic appendicectomy, Ernest Codman offended his Boston colleagues with a cartoon (figure⇓) mocking their indifference to outcomes and asking, “I wonder if clinical truth is incompatible with medical science? Could my clinical professors make a living without humbug?” Looking at the rates of tonsillectomy in London boroughs in the 1930s, John Alison Glover discovered that they were entirely governed by the policy of school doctors and bore no relation to need or outcomes. John (Jack)Wennberg established the science of outcomes research when in 1973 he described patterns of gross variation in the use of medical and surgical procedures in the United States, which lacked any clinical rationale but was closely related to supply. Diagnosis drives treatment, and in recent years the term overdiagnosis has been used to describe various situations where diagnoses lead to unnecessary treatment, wasting resources while increasing patient anxiety. Overdiagnosis can be said to occur when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis.” Overtreatment includes treatment of these overdiagnosed conditions. It also encompasses treatment that has minimal evidence of benefit or is excessive (in complexity, duration, or cost) relative to alternative accepted standards. 5 A recent report by the Academy of Medical Royal Colleges argued that doctors have an ethical responsibility to reduce this wasted use of clinical resource because, in a healthcare system with finite resources, one doctor’s waste is another patient’s delay. Choosing Wisely in the NHS