Oliver Peters, Vice President of the Swiss Federal Office of Public Health (FOPH), encourages doctors to make realistic decisions, in line with the patient’s wishes, to provide quality health care.
IV-The “less is more” movement advocating less medical care is taking off in western countries. What does that mean to you?
OP-We have made the same observations as the “Too Much Medicine” campaign. It’s a complicated issue, but we have isolated several factors and are already taking action. The main focuses are the fragmentation of health care and excess supply of highly specialised and therefore more costly services.
OP-High-tech services such as scans or MRIs. Not only are they sometimes performed without being truly necessary, these services are extremely expensive. Innovation generally contributes to lowering costs (aviation, construction, etc.), but in health care, prices haven’t changed since the 1990s!
IV-Are certain categories of patients more directly concerned?
OP-Older patients typically need more medical services and are therefore affected more, but it’s not just an issue of age group. Generally speaking, a huge contradiction has developed between increasingly sick patients – who need more advanced and integrated patient care planning – and the growing fragmentation of health care that focuses on episodes or individual therapeutic steps. That’s why I think that analytical, integration and planning skills should also be strengthened in medicine, as was seen in other service-based sectors such as banking, insurance and engineering in the 1980s and 1990s. Patient care plans, because that’s actually what we’re talking about, should be used more.
IV-Is this approach also useful for patients at the end of their life?
OP-Most certainly. The Swiss newspaper NZZ published a study comparing end-of-life care in the United States and Switzerland1. This situation is over-medicalised in both countries. In Switzerland, a high number of hospitalisations and aggressive therapies (chemotherapy, radiotherapy, etc.) were reported in the last month of life. And procedures were performed more frequently on patients with supplemental insurance coverage. In the United States, despite the Patient Self-Determination Act passed in 1990, patients are treated more aggressively than they would like, and they are not treated in the way that their general practitioners would choose for themselves in a comparable situation.
IV-What measures are recommended to change that?
OP-The US study explained that modern medicine is based on a principle of maximum therapy for everyone, and the system’s financial incentives encourage a treatment programme that patients wouldn’t spontaneously choose. It also reported how unsafe situations are especially vulnerable to over-medicalisation. It’s easier to initiate or continue an intensive treatment than to stop it. General practitioners have to face difficult discussions with the patient or their loved ones. They must also accept full responsibility if they decide that an aggressive treatment is not or no longer appropriate. And doctors often have no one to turn to when dealing with an unsafe situation. So many factors are swinging in the direction of “Too Much Medicine”.
"I think we can expect something comparable to the revolution brought by CT scans and MRIs, except that it’ll be 100 times stronger."
To counter that pressure, realistic patient care plans that are continuously adjusted and in line with the patient’s wishes offer the fundamental cornerstone for providing quality health care. I also think that another key response is access to specialised expertise to aid in decision-making in challenging environments (emergencies, intensive care). Lastly, I believe it’s essential to allow patients (and their loved ones) to take control of some decisions about their treatment, especially at the end of their life. Exit cannot be the only solution.
IV-So you think we need to change the way we view medicine.
OP-Definitely. The “pathologisation of human life” (F. Domenighetti) is spreading fast, as demonstrated in the debates over personalised medicine or new names for diagnoses. At the same time, we tend to attach too much value to specialised procedures, i.e. those that supposedly save lives, rather than the first steps in the care process. But the real added value, which affects all the care administered and the patient’s life, is a proper diagnosis and the right therapeutic approach!
But that change in culture won’t happen in just a few months. I’d just like to mention how interesting it is to observe what’s happening in paediatric and neonatal units. Like all other clinical specialities, care for children has benefited over these past few years from extraordinary advances in technology and available treatments. However, other units haven’t seen the same development. In paediatric and neonatal units, professionals are much more careful about assessing the patient’s situation and any unnecessary suffering. They also listen carefully to what the family wants, without exaggerating the heroism of the individual therapeutic act. That may be the evidence of a suitable relationship between the patient and health care provider and between the health care provider and the arsenal of therapies available.
(1) "Mehr ist nicht immer besser: Übertherapie am Lebensende", NZZ 26.6.2014
IV-You haven’t mentioned the rise in the price of drugs...
OP-This issue actually has little to do with drugs. The percentage spent on drugs by compulsory insurance has remained stable, or even slightly decreased, partly due to the price cuts imposed by the FOPH over the past three years. But we are definitely seeing dubious commercialisation policies and prices for some new cancer and antiviral therapies. Moreover, many drugs are prescribed simultaneously and without adequate coordination between different services. And this remains a concern, especially for older people. A nationwide programme entitled “Avoiding medication errors in hospitals” was launched to address this issue.
IV-Many people are talking about population ageing expected in the future. But you make it sound as though the situation is already alarming.
OP-Indeed, the figures from the Swiss Federal Statistical Office are impressive. Between 2001 and 2012, the number of people over 70 admitted to emergency departments increased 70%! The care provided before, during and after hospitalisation must be reassessed starting now. To what extent is this increase due to a lack of capacity or the inadequate organisation of the outpatient care system? And to what extent are people overly reliant on the hospital system, and can that be avoided?
IV-Will this type of situation worsen with the emergence of genomic medicine?
OP-I think we can expect something comparable to the revolution brought by CT scans and MRIs, except that it’ll be 100 times stronger. The ability to detect abnormal situations or predispositions to disease will increase rapidly, but we won’t necessarily be able to properly assess or treat what we find. And that gap risks lasting quite some time and causing a feeling of considerable insecurity in patients. We will inevitably see the development of new therapies – without adequate study of their main consequences and side effects – invading the market to meet that demand.
IV-Have health offices in other countries made observations comparable to ours?
OP-Everyone is asking the same questions and agrees that guidelines alone will not be enough to prevent practising too much medicine. Health offices must each act within their country’s specific environment and public health budget. We’ve already noted that it’s always more difficult to steer and calibrate the offer of medical services when the health care system leaves significant leeway for regional interpretation and the private sector, as is the case in Switzerland. But population ageing will clearly force all countries to rethink their priorities and the organisation of their health care system. Nations will have to join forces to deal with the next waves of innovation, as well as price hikes, which is why we have already developed strong ties with our European counterparts.