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Choosing wisely…

“I’m busy doing nothing.

Working the whole day through.

Trying to find

Lots of things not to do.”

The Bing Crosby song, Busy Doing Nothing, played in my mind as I read a recent report on 40 treatments and procedures that are of little or no benefit to patients, published as part of the Choosing Wisely initiative by the Academy of Medical Royal Colleges.

Choosing Wisely UK is part of a global initiative that aims to reduce waste in healthcare and avoid the risks of unnecessary tests and treatments. Twenty-three Royal Colleges of the UK and Ireland were asked to examine the most recent evidence and select five interventions that they considered unnecessary, put together a report and distribute this information to their members. In other words, they were asked to find ‘lots of things not to do’. Pen poised, I scrolled their lists, eager to make my own ‘not to do’ list, hopeful that this might be the antidote to a constant nagging feeling that much of my working day could be interpreted by some as ‘keeping crickets cheerful’ or ‘watching the river, to see that it doesn’t stop’, to quote another verse of the song.

The full report can be accessed at www.choosingwisely.co.uk. Those of you who are not too busy, can listen to the song at www.youtube.com/watch?v=jYylMR3Tj8M.

My list consists of: Cessation of all medications not used for symptom control in elderly, frail patients; no routine FSH testing in women over 45 who have amenorrhoea; no imaging for suspected polycystic ovarian syndrome in the absence of relevant hormone measurements; no commencement of preventative medications in asymptomatic patients without fully informed consent; no routine checking for IUCD strings in a woman who can check them herself; no imaging for minor head injuries or back pain without red flag signs or symptoms and my favourite – no routine cholesterol testing for patients on statins who do not have additional risk factors.

The authors of the Choosing Wisely report met regularly over a two-year span, referenced many academic papers and collated opinions from numerous experts, before launching their report.

Gather together any group of GPs and they will come up with a much longer list of pointless activities that fill our days, without any reference to academic journals or experts. Letters for housing grants, sick notes for school children, the well-person ‘check-up’, retrospective letters for the emergency department to save patient fees, scripts for sleeping tablets, cough medicines, antibiotics for sore throats, anxiolytics for those afraid of flying, are some of the more common ones. Triplicate form filling for leave payments, Kardexes for nursing homes, medicals to say over-70s are safe to drive, pre-employment medicals, and fitness to travel certificates are also frequent flyers. Weighing and measuring healthy children was added to the hoop-jumping activities last year with the introduction of the under-sixes contract. 

Where is the evidence for these activities? There isn’t any. And it is time for grassroots GPs to stop doing them. Time to say ‘no’ to tests and treatments that are not beneficial. Time to stop the nonsense box-ticking and form-filling imposed on us by organisations that have no understanding of what we do. Time for us to act like the evidence-based profession that we are. If general practice is to survive, with the limited resources available, we must stop being busy doing nothing and decide what it is we will not do. 

Doctors are not blameless when it comes to pointless busyness. We frequently order a battery of blood tests on healthy individuals without considering that we will have to interpret them, explain them, and even repeat those that fall outside the lab’s normal parameters, even while strongly suspecting that they are not significant.

We feel sorry for the socially deprived individual that cannot get a housing grant and write them a ‘very strong’ medical letter knowing that it will make very little difference and is very likely to end up in a council office bin.

I know I have given antibiotics for sore throats because I perceived that the patient expected it and would almost certainly attend the out-of-hours services if they did not get it from me. But antibiotics are harmful when over-used, social housing grants should not depend on how many illnesses a person has and there is no evidence that everyone over 70 needs a doctor to certify them as fit to drive.

Saying ‘no’ is not the easy choice but it is often the wise one. It does not mean doing nothing. It involves actively engaging with society and organisations in order to encourage realistic expectations of GP services. It involves understanding the patient perspective but also helping patients understand ours so that we can be busy providing care that will be meaningful, rewarding and of definite benefit to patients, doctors and society.

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