When a friend finally arranges the chat we were meant to have some weeks ago, she apologises profusely for the lack of contact. I tell her she doesn’t need to mollify me but it turns out she is the one in need of sympathy. Her husband had gone into hospital for what was termed a routine procedure. While waiting to collect him, my friend suddenly heard the overhead announcement of a code, announcing a patient in extremis.
“Something told me it was him.”
The surgery had unleashed a bacterial shower, rendering him septic on the operating table.
Fortunately, he was in a hospital with an intensive care unit, where he found himself for days receiving life-sustaining treatment. He recovered but I could still feel her palpable fear at the prospect of losing her husband on an ordinary day.
In this case, the procedure was necessary. But just that week, another friend had undergone a gastroscopy to re-examine a gastric ulcer. Afterwards, she reported that the gastroscopy had been fine but the colonoscopy was “pristine”.
“Why did you need a colonoscopy?” I asked.
“They just did it.”
“Do you know why?”
‘I guess it was routine.’
I didn’t press the point but these two accounts had me reflecting on how doctors and patients think about interventions.
For clinicians, routine simply describes familiarity and frequency. A routine procedure can be safe or low-risk but not no-risk. But patients might hear routine as reassurance that nothing serious can happen. These are two very different propositions.
Take colonoscopy, for instance.
With the rising incidence of bowel cancer, this is the gold standard test for early detection and improved survival. But the fact that it is familiar doesn’t mean it is benign.
Bowel preparation can cause dehydration and electrolyte imbalance. The procedure can result in bleeding and, rarely, perforation and sedation carries its own risks. All the risks are increased in elderly people. Many colonoscopies won’t find disease and some that find a minor abnormality trigger additional procedures not strictly needed.
Even a small risk of complications multiplied by millions of colonoscopies produces a substantial number of people who are harmed.
If you have ever had a course (or three) of antibiotics “just in case”, you are in the 40% of the global population that leave the doctor’s office with an antibiotic prescription. Of these prescriptions, nearly 60% are unnecessary.
Antibiotics are not a procedure but they are an extremely common intervention with potent downstream effects on a complex ecosystem.
Apart from the “routine” side effects of rash, nausea, altered taste and diarrhoea, a dreaded result of antibiotic overexposure is the altered gut microbiome that predisposes to C difficile infection. And 70% of people who develop this obstinate diarrhoeal condition have received antibiotics in the past 12 weeks.
Antibiotic resistance is another concern. If more than a million people each year die from the direct result of drug-resistant infections, no antibiotic prescription can be labelled routine.
Useful yes, routine no.
When I was an error-prone medical student, the emergency department was the place to be when it came to practising IV insertion. After all, everyone “needed” an IV – and “routine” bloods to boot – even before they met a real doctor who could assess their need.
Alas, little has changed in 25 years. By way of apology to those hapless patients, today I sound like a complete bore, peeking under every sleeve and bandage at every bedside.
“Why is there an IV?”
The commonest answer? “It was already in.”
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IV insertion is the most common invasive procedure performed in hospitals today – a billion such procedures a year, many done unquestioningly though the problems are well documented, from the pain of serial attempts (just ask my cancer patients) and local irritation to serious infection.
Somewhere along the line, as healthcare discoveries grew more abundant and doctors felt increasingly well equipped, the idea that each intervention has its own toxicity slipped into the background. The distinction blurred between something being medically available and medically useful.
A cynical take is to blame financial incentives but as a public hospital doctor, I see other forces at play: fragmented care, diagnostic uncertainty, unrealistic expectations and a lack of time offset by a battery of tests.
Unnecessary care harms the recipient but it carries a second, quieter cost. Unnecessary care compromises necessary care.
My most disadvantaged patients rarely know how to advocate for themselves; they only know to wait in line. If your child is injured in a sporting accident and a scan is weeks away or you need an urgent colonoscopy but it’s many months away, there is a reason. Healthcare is a finite resource; money, time and doctors’ attention devoted to low-value care are diverted from people with genuine need.
The lesson for patients is that there are routine procedures and necessary procedures but no risk-free procedures. So, if you are a patient, please ask more questions. Why do I need it? What are the alternatives? What happens if I don’t have it?
Doctors, meanwhile, should remember that familiarity does not equal harmlessness. Truly informed consent means telling patients honestly about how routine procedures can go awry.
Good medicine isn’t necessarily more medicine or less medicine. It is the right medicine, for the right patient, at the right time.
