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Experts caution against idea that more is better in medical care

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Staff Writer

Since Japan established universal health coverage in 1961, it has ceaselessly worked to expand its health care services, in the belief that providing more extensive coverage for a wide variety of patient needs will contribute to the well-being of its citizens.

But an increasing number of experts are questioning the idea that more care is better. They say over-diagnosis and over-treatment can inflict more harm than good, and urge doctors and patients to be more selective about medical screenings, treatments and procedures.

There is also a growing need to cut back on waste and unnecessary care as the nation’s population grays and shrinks, while a new class of super-expensive drugs are putting immense strain on the system.

It is under these circumstances that a group of doctors and citizens established last year Choosing Wisely Japan, expanding a U.S.-born campaign that has spread to about 20 countries.

Last week, the Japanese Association of Medical Sciences, an academic confederation under the Japan Medical Association, held a symposium in Tokyo featuring several campaigners for Choosing Wisely Japan.

Dr. Shunzo Koizumi, a physician and professor emeritus at Saga University Faculty of Medicine, explained how the movement took off in the U.S. after physician Howard Brody published a paper in the New England Journal of Medicine in 2010. In the paper, he called on each group of specialist doctors to identify five tests and treatments that were considered overused in their fields yet provided little benefit to patients, arguing that doing so — and stopping health care costs from “zooming out of control” — is the medical profession’s “ethical responsibility.”

The ultimate goal of the movement is not just to cut costs but to promote better communication between physicians and patients, so they can engage in “shared decision-making,” Koizumi said.

Building on Brody’s work, the Philadelphia-based ABIM Foundation, created by the American Board of Internal Medicine, tied up with nonprofit group Consumer Reports in 2012 to formally launch the Choosing Wisely campaign. More than 70 medical societies in the U.S. comprising over 1 million clinicians have now published “top five lists.”

The list compiled by the American Society of Breast Surgeons, for example, discourages a routine double mastectomy for patients with cancer in only one of their breasts, citing the generally low risk that they will develop cancer in the other breast and the minimal effectiveness, if any, of a double mastectomy improving their life expectancy. It also recommends that doctors not perform a routine breast MRI in new breast cancer patients, saying it could lead to unnecessary biopsies and mastectomies.

Dr. Yasuharu Tokuda, a general practitioner from Okinawa, said Japan has its fair share of unnecessary, scientifically unproven care, including the excessive use of CT scans.

According to the latest statistics from the Organisation for Economic Co-operation and Development, Japan has by far the largest number of CT scanners per capita in the world, with 107 machines for every 100,000 people. That’s nearly double the figure in Australia, which ranks second, and more than four times the OECD average of 25.

Abuse and overuse of antibiotics, which can lead to antibiotic resistance, also need to be kept in check, Tokuda said.

He also recalled the case of an 85-year-old man who visited his hospital two years ago. The patient was in miserable shape, suffering from a plethora of conditions, including schizophrenia, Parkinson’s disease and a decline in cognitive functions. The patient also suffered from diarrhea and had difficulty swallowing food. He had been prescribed over 15 antipsychotic and other drugs.

“This was a case of the so-called prescription cascade,” Tokuda said.

Prescription cascade refers to a problem in which the side effects of drugs are misdiagnosed as symptoms of another condition, which leads doctors to prescribe more drugs. But this triggers further side effects and unanticipated drug interactions, resulting in even more misdiagnoses and symptoms.

“His symptoms subsided after we cut back on drugs. Seven days later, he was able to have meals by himself. We eventually managed to cut the number of drugs he took to three,” he said.

Kyoko Kitazawa, a medical journalist and visiting professor at Kyoto Pharmaceutical University, acknowledged the challenges in getting people to provide less care. All stakeholders, including doctors and patients, are naturally incentivized to do more than less, she said.

“Medical professionals want to do all they can to cure patients,” she said. “Some of them also might have regrets about past cases where they could not provide sufficient care soon enough. The media feel justified in raising awareness of diseases, and for hospital management, more treatment means more revenue. Moreover, patients are fearful of not doing enough to improve their health.

“But every procedure has its benefits and risks. Patients need to weigh both, and make health care decisions by talking them through with their doctors.”

A Matter of Health is a weekly series on the latest health research, technology or policy issues in Japan. It appears on Thursdays.