The deprescribing trend
Deprescribing is a niche that is coming into its own. Research seems to be bubbling up everywhere that’s about reducing medications. As a ready reckoner, I did a quick search on PubMed for articles mentioning ‘deprescribing’. There were just 37 articles in 2015 but it had risen to 182 in 2018. At the end of October 2019, there were over 200 and it is rising quickly. This could all be down to the popularisation of the term but I believe it’s a marker of the medical profession’s ennui — we’re heartsick of the guideline-driven industrialisation of medicine. There is a lurking discontent about the harm we’re doing to people with medications and we’re rowing back. Deprescribing is a reaction.
Medicalisation is much discussed but who would dare suggest we’re making much progress in the profession? Research suggests ever more medical conditions and more indications for treatment. Various organisations, sometimes framed as overdiagnosis groups, have pushed back, though, paradoxically, they swing the sword of evidence to demand fewer diagnoses and medicines. It’s worthy, though there is a risk that overdiagnosis movements prioritise the problems of the privileged — after all, you have to have contact with the healthcare profession to have a diagnosis and even in the UK, never mind the poorest countries in the world, our most vulnerable populations are underserved. As so often, it feels like we need a redistribution of our efforts.
Illich and cultural iatrogenesis
It was the social philosopher, Ivan Illich, in his book Limits to Medicine that lit up the debate on medicalisation when it was published in 1976.1 Illich was writing before the 1980s and the free-market medico-industrial machinery clamped us in its jaws. The writing is, unsurprisingly, dated in places, but more often it’s deeply prescient and Illich’s comments and predictions are more salient than ever. He is quick to highlight the same point as the overdiagnosis groups — that ‘most of today’s skyrocketing medical expenditures are destined for the kind of diagnosis and treatment whose effectiveness at best is doubtful’. Illich gave a potted summary when he lectured the 1982 RCGP Spring General Meeting and the BJGP published it in full.2 Overprescribing and overdiagnosis are obvious medicalisation but Illich argued that even the lifestyle discussions we offer to patients are a cultural iatrogenesis. It often feeds into an ‘automedicalisation’ where people are then exhorted to self-monitor, check their own BP, constantly fretting about their wellbeing. He stated: ‘Medicalisation occurs whenever some aspect of ordinary, everyday life comes to be so defined that it requires input from an institutionalised medical system’ and whenever we medicalise, so Illich would have it, then we cause harm. And, there are no better examples of Illich’s cultural iatrogenesis than the vogue for non-pharmaceutical prescribing.
Extending deprescribing
It should provoke a wave of revulsion when normal activities of human life are offered on a notional FP10 as a prescription. If we really want to demedicalise then the answer is obvious: doctors shouldn’t be involved at all. Lifestyle medicine gurus, wellbeing practitioners, and complementary practitioners should hold off on their cheers — Illich was just as damning, also regarding them as medicalisation, promoting ‘at least as much dependence as a medicalising general practitioner’.
In the past week alone, I’ve read articles that have stated doctors should start issuing nature-based prescriptions to get people to spend more time beside the ocean; and we should prescribe singing for various mental ailments. And, of course, there is the daddy of them all: social prescribing. We are medicalising conversation, medicalising walks on the beach, medicalising even the simple pleasure of singing. We need, as Richard Smith put it in 2001, to rip up the ‘bogus contract’ with patients, accept that pain, illness, and death do happen and we often have a limited ability to manage them.3 We certainly need to reduce unnecessary drug prescriptions but perhaps the more honest relationship with patients he recommends needs an extended, purer, form of ‘deprescribing’. We can’t undo the harms of medicalisation by medicalising every facet of human life. A simple step would be to stop using language that implies every human activity can be offered on a prescription. Now that would be deprescribing.
- © British Journal of General Practice 2019