The Difficult Choice of "Not Doing"

Abstract

The article of Marc Jamoulle shows the importance of the contribution of general practitioners (GPs) in improving the quality and the efficiency of the health systems. Starting from the concept of quaternary prevention for reducing excessive costs in the preventive procedures, he suggests a change of paradigm in every daily activity of the GP in order to have a stronger ethical approach to the patient. This means spending more time in the consultation in order to better understand her/his real needs and share a common decision for minimizing the costs and solving the patient’s problems in agreement with her/his believes and values.

I had the honour of being involved in the review of the article “Quaternary prevention, an answer of family doctors to overmedicalization”¹ but most of all, I am proud to personally know the author, Marc Jamoulle.

I believe that a commentary is worth making on this article because it emphasizes the different points of view amongst public health workers, family physicians and patients. Public health workers often “scotomize” the activity of general practitioners (GPs) as they are primarily concerned with ensuring the highest level of performance with the least cost.²

The growing workload in general practice with the consequent short consultation time determines a rapid agreement to demands from the patient, which is frequently inappropriate and can contribute to overmedicalization. On the contrary, longer consultation time is associated with a range of better patient outcomes.³

An easy way for GPs to work is to:

1. listen to the complaint of the patient

2. transform the complaint into a diagnosis

3. prescribe a diagnostic procedure and treatment of the disease, according to the request of the patient

It is an easy way which is both well-recognized by public health workers and welcomed by patients.

1. But Jamoulle’s article proposes a different and more ethical approach to the GP’s relationship with the patient:

2. Listen to the complaint of the patient and understand/highlight the possible hidden agenda of the patient.

3. Inform the patient of the diagnosis as well as the ‘pros’ and ‘cons’ of further diagnostic procedures and further treatment.

4. Share with the patient the decision to “do” or “not to do”, according to the doctor’s technical knowledge and the patient’s ethical values.

In this way Jamoulle is expanding the concept of quaternary prevention: it is not only a matter of “doing” or “not doing” a preventive procedure, but it is widening the GP’s style in every decision of their daily activity.

Minimizing healthcare costs is the usual yet difficult objective of every public health officer, and the most normal way is to ask doctors to follow evidence-based medicine (EBM) guidelines that may sometimes spare some money.⁴ This means that GPs should focus their intervention on the disease that is presented to them. What happens, however, in a GP’s office is somewhat different: patients arrive with undefined and confused symptoms because they often present multimorbidity and very often they bring other problems unrelated to the first disease (usually each patient comes to their GP’s office with an average of 3 different problems).

In such a situation, the suggestion of M. Jamoulle is to focus not solely on the disease, but rather on the relationship with the patient, emphasizing his/her beliefs and values. He proposes dedicating more time (but saving money in prescribing cheaper diagnostic and therapeutic procedures) to understanding the goal of the patient in order to reach an agreement before taking any decision.

Moreover, the slow medicine movement is acting in avoiding unnecessary expenses for the National Health System (NHS), but in this case the focus is again on the disease⁵ (find 5 procedures that can be avoided in your speciality) while the philosophical extended version of Jamoulle quaternary prevention is paying more attention to the needs of the individual patient and try to answering his/her problems by reaching a common, mutual agreement.

This approach may initially appear to be a waste of time, but on the other hand it is worth matching both the needs of the patient with the possibility of saving money by “not doing” a medical procedure which may indeed become overmedicalization. Obviously the choice of “doing” (by which I mean agreeing without discussion to all the patient’s demands, prescribing all available diagnostic procedures, treating all pathologies) is much easier. Yet “complexity” is one of the main characteristics of a GP’s occupation. This means:

• knowing the choice of EBM

• understanding the real needs of the patient by following the history of his/her disease and his/her life history

• and finding a way to share a common, joint decision in order to resolve his/her problems.

Ethical issues

Not applicable.

Competing interests

Author declare that he has no competing interests.

Author’s contribution

GV is the single author of the manuscript.

Citation: Visentin G. The difficult choice of "not doing": Comment on "Quaternary prevention, an answer of family doctors to overmedicalization". Int J Health Policy Manag. 2015;4(8):559–560. doi:10.15171/ijhpm.2015.108