Carrie MacEwen

Professor Carrie MacEwen is Chair of the Academy of Medical Royal Colleges and Consultant Ophthalmologist at Ninewells Hospital, Dundee.

So, what is Rethinking Medicine and exactly what needs to be re-thought? Medicine is constantly changing – so, what has happened that requires us to rethink the process and perhaps bring it back into line?

Medical training and care provision have developed throughout the centuries to recognise the current knowledge as well as reflecting disease profiles and social mores. It is imperative that medical training and on-going professional development are based on the needs of individual patients and the population who will benefit from the resultant knowledge and skills. 
Thus, leeches, blood-letting, arsenic, or even gastric ulcer surgery and paediatric aspirin, do not feature in today’s curricula as they are not used routinely in modern medicine. Conversely, previously absent information about whole genome sequencing, end of life care and community physiotherapy are now included, recognising developments in both medicine and the way health care is delivered.
New technologies, different disease profiles, societal behaviours and evolving evidence change what we learn and therefore, ultimately, how we deliver care.

Importance of practicalities  

Practicalities such as affordability, individual preferences and risks associated with these developments, may not always be given the importance they deserve due to the constant desire, on the one hand, to continue with what we are comfortable doing and, on the other hand, to use commonly under-evaluated exciting new drugs and interventions.
Terms such as over-diagnosis and over-treatment, social prescribing and shared decision making would not have been recognised a decade ago, just as ‘evidence-based medicine’ was not a known term until the 1970s. The emphasis on treating the sick in hospitals using the newest, most advanced methods is understandable in this era of genomics and artificial intelligence – but is this right or always what people want or need?
Firstly, the direction of travel should be towards health and keeping the population well rather than on concentrating on managing sickness. This means promoting healthy lifestyles, reducing obesity and preventing high risk behaviours.  

​Screening appropriately also helps but definitely not the indiscriminate search for disease without understanding what this might mean for people and their families. Acknowledging the risks and potential harms of over-investigation with resultant over-diagnosis and over-treatment is vital in this time of availability but limited knowledge beyond direct management of illness and disease.

What is the best course of action for that whole person in their own specific circumstances?

Secondly, individual differences and choices need to be considered more carefully to determine what is the best course of action for that whole person in their own specific circumstances. The patient selected option may not include the addition of an effective, but non-desired drug, or even provide the chance of longest survival; but one that has been decided through an evidence based, shared decision-making process that recognises the patient’s own values and desires.
Developments in medical science have offered, and continue to offer, new investigations and treatments that deliver significantly better management of disease processes with resultant welcome increased longevity.

​The need and ability to constantly innovate benefits us all, and with it comes an understandable enthusiasm to use the new developments. However, simpler, non-interventional methods are more desirable for many, depending on age, concomitant morbidity, beliefs and personal circumstances and therefore, should be employed.

Issues that need rethinking

There are many issues that need to be rethought in medicine today, which is more a re-focus back to the ancient ‘do no harm’ rather than a truly new way of thinking:

  • The keenness to intervene just because it is possible ‘to do something’, should be secondary to what is the best thing for that patient or population.
  • The understanding and acknowledgement of potential harm associated with every investigation, drug prescription or intervention; this should be balanced against possible benefits and those of other alternatives.
  • Understanding the whole person, the intricacies of living with multi-complex disease and interaction with social care and personal circumstances.
  • The emphasis on prevention of disease through personal lifestyle improvements. Screening and preventative measures may provide better  disease outcomes where appropriate criteria are fulfilled – but NOT where they are not as this leads to over-diagnosis, over-treatment and anxiety causing harm rather than benefit.
  • The vital role of the individual in deciding what is their best preferred (evidence based, where possible) option. All should be offered the Academy of Medical Royal Colleges’ Choosing Wisely UK BRAN principles when coming to their decision of any investigation or intervention. These  are to consider:
    • Benefits
    • Risks
    • Alternatives, which include
    • doing Nothing

In order to be in a position to deliver this change, there is even more need for doctors to be knowledgeable about the scientific basis of diseases and modern treatments. To be able to reach a working diagnosis through careful clinical evaluation remains essential – or to be in a position to reassure by excluding or monitoring for potentially serious conditions – and then to further evaluate and articulate what management might be possible requires more skill than offering an investigation, a prescription or a standard treatment. 
It is impossible to deliver without being fully cognisant of how to form a differential diagnosis (which may include uncertainty) and understand how possible management plans may affect the whole person. This re-think is not a move away from the traditional bio-medical model of teaching and delivering medicine, but a broadening of the alternatives in a positive, patient centred way.

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