Key points
- Over Medicalisation in musculoskeletal practice: The article highlights the growing issue of over medicalisation, where normal physiological conditions are being unnecessarily treated as medical problems, leading to overtreatment and potential harm to patients.
- Examples of unnecessary interventions: The article provides concrete examples of unnecessary medical interventions in musculoskeletal practice, such as the overuse of diagnostic imaging and orthopaedic surgeries, which often do not improve patient outcomes.
- Impact of financial incentives: The authors discuss how financial incentives within the healthcare system contribute to the overuse of medical treatments, as more invasive and expensive procedures are often financially rewarded, despite their limited benefit.
- Recommendations for reducing unnecessary care: The article offers suggestions for reducing over medicalisation, including the promotion of evidence-based care, encouraging shared decision-making between clinicians and patients, and removing financial incentives for low-value care.
- Role of patients and clinicians: Patients are encouraged to ask informed questions and consider conservative management options, while clinicians are urged to practice evidence-based medicine, avoid unnecessary imaging, and educate patients on the risks and benefits of different treatment approaches.
Overview of the article
The article “The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice” explores the issue of over medicalisation in musculoskeletal healthcare. It argues that the overuse of diagnostic tools and treatments, driven by the belief that more care is always better, is leading to unnecessary medical interventions and the medicalisation of normal physiological conditions. This trend wastes healthcare resources and exposes patients to unnecessary risks without providing proportional benefits.
What is the problem at hand
The primary issue addressed in the article is the overdiagnosis and overtreatment of musculoskeletal conditions. The authors emphasise that excessive use of medical interventions, such as unnecessary imaging and surgeries, leads to what they term “too much medicine.” This problem is compounded by the medicalisation of normal variations in the human body, where normal age-related changes or minor discomforts are treated as pathological conditions that require intervention.
What is the author’s main line of argument
The authors argue that the current approach to musculoskeletal healthcare is excessively aggressive, often leading to unnecessary treatments that do not improve patient outcomes. They contend that this approach is driven by a combination of factors, including the desire to “do something” rather than take a conservative approach, the influence of financial incentives in the healthcare system, and the fear of missing a diagnosis. This has created an environment where more care is mistakenly equated with better care.
How do they support this line of argument
The authors support their argument by providing examples of overdiagnosis and overtreatment in clinical practice. They discuss the overuse of diagnostic imaging, such as MRIs, that often reveal “abnormalities” which are simply normal variations and do not correlate with pain or dysfunction. The article also highlights the overuse of interventions like opioids and surgeries, which are sometimes prescribed without sufficient evidence of their necessity or efficacy.
What are examples of too much medicine relevant to MSK practice?
- Nonsurgical Interventions for Pain: The article describes how various nonsurgical treatments, including acupuncture, manual therapy, and the use of opioid analgesics, are often overused in the management of musculoskeletal pain. Despite their widespread use, these interventions may not always be necessary or effective, leading to unnecessary costs and potential harm to patients.
- Orthopaedic Surgery: Another example provided is the overuse of orthopaedic surgeries, such as arthroscopic procedures for knee osteoarthritis or repairs for nontraumatic meniscal tears. The authors argue that these surgeries often do not perform better than less invasive treatments and may expose patients to unnecessary risks.
What are examples of medicalising normality relevant to Physiotherapy
- Postural “Abnormalities”: The article explains how normal variations in posture, such as slight kyphosis or scoliosis, are sometimes labelled as pathological conditions that need correction. This medicalisation of normal postural variations can lead to unnecessary interventions, such as corrective exercises or even surgeries, that do not necessarily improve patient outcomes.
- Imaging “Abnormalities”: The identification of so-called “abnormalities” on imaging studies, such as disc bulges or rotator cuff tears, in asymptomatic individuals is another example. These findings are often just normal age-related changes, yet they are sometimes used to justify invasive treatments, leading to the medicalisation of normal ageing processes.
What are the suggestions for change
The article offers several suggestions for addressing the problem of too much medicine in musculoskeletal practice. These include:
- Promoting evidence-based care: Physiotherapists should prioritise treatments that are supported by strong evidence and avoid those that have not been proven to be effective.
- Encouraging shared decision-making: Patients should be fully informed about the potential benefits and risks of different treatment options and should be involved in making decisions about their care.
- Reducing financial incentives for unnecessary care: Healthcare systems should align financial incentives with the provision of high-value care, rather than rewarding the use of more expensive or invasive treatments.
What can patients do?
Patients can take an active role in their healthcare by:
- Asking informed questions: Patients should inquire about the necessity of proposed treatments, including the potential benefits and risks.
- Considering conservative management: Before opting for surgery or other invasive treatments, patients should consider whether less invasive options, such as physiotherapy, might be effective.
- Seeking a second opinion: If a diagnosis or treatment recommendation seems overly aggressive, patients should feel empowered to seek a second opinion.
What can clinicians do?
Clinicians can contribute to reducing over medicalisation by:
- Practising evidence-based medicine: Clinicians should stay informed about the latest evidence and apply it to their practice, avoiding interventions that are not supported by strong evidence.
- Educating patients: Clinicians should help patients understand their conditions and the range of treatment options available, including the potential for “watchful waiting” in cases where immediate intervention may not be necessary.
- Avoiding unnecessary imaging: Clinicians should use imaging judiciously and avoid ordering tests that are unlikely to change the management of the patient’s condition.
References
Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. Journal of Orthopaedic & Sports Physical Therapy, 50(1), 1-4. https://doi.org/10.2519/jospt.2020.0601
Frequently Asked Questions
What is overdiagnosis in musculoskeletal practice?
Overdiagnosis refers to the identification of abnormalities that are not likely to cause symptoms or affect a patient’s health. In musculoskeletal practice, this can occur when normal age-related changes or minor anatomical variations are labelled as conditions requiring treatment.
How can I avoid unnecessary treatments for my musculoskeletal pain?
To avoid unnecessary treatments, patients should ask their healthcare providers about the necessity of proposed interventions, consider conservative management options first, and seek a second opinion if unsure.
Is surgery always necessary for musculoskeletal conditions?
No, surgery is not always necessary. Many musculoskeletal conditions can be managed effectively with physiotherapy and other conservative treatments. Surgery should be considered only when these options have been exhausted or are not appropriate.
What are the risks of overusing diagnostic imaging like MRIs?
Overusing diagnostic imaging can lead to the identification of incidental findings that may not be clinically significant. This can result in unnecessary anxiety, further testing, and potentially unnecessary treatments.
How can I tell if a treatment is truly necessary?
Patients should discuss the potential benefits and risks of any proposed treatment with their healthcare provider. It’s also helpful to ask whether the treatment is supported by strong evidence and if there are less invasive alternatives.
