For decades, millions of patients have taken aspirin daily to prevent heart attacks and strokes.
But in March 2019, the American College of Cardiology and the American Heart Association issued clear guidelines: healthy adults with average risk of heart disease do not benefit from taking an aspirin every day.
In simple terms, aspirin, or acetylsalicylic acid, is now a "low value medical care".
The term was coined to classify tests and medications that are ineffective and that do not bring any benefit to a patient. Instead, low value-added care can actually expose patients to harm, divert their attention to truly beneficial care, and result in unnecessary costs for both themselves and the health system.
Since entering medical school almost 10 years ago, and now as a family doctor, I have noticed that there is a growing need to identify and eliminate low-level medical care. added value.
In the case of aspirin, research shows that patients at medium risk are at higher risk of bleeding and that their daily intake makes them believe, wrongly, that it is the best form of prevention.
In fact, the best protection against heart disease is regular exercise, a healthy diet and prevention of smoking.
Health care systems are slow to respond
Convincing doctors to stop making a recommendation for a low-value drug is a slow and arduous task.
It is no secret that health care systems are slow to integrate new research into clinical practice. A historical study in the early 2000s showed that 17 years is needed before the results of a research are incorporated into regular care.
The evolution of clinical practice also goes beyond the integration of new information. It is necessary to unlearn outdated and ineffective clinical practices, which health systems are attempting to do with great difficulty.
This partly explains why low value-added health care continues to flourish – $ 765 billion in 2013 in the United States and becomes unproductive.
Doctors practice defensive medicine
Part of the challenge of unlearning is that it interrupts the status quo for both physicians and patients. For example, in previous decades, family physicians provided all patients with an annual physical examination and routine blood tests. We thought that this annual check would help detect diseases and improve the health of patients.
Instead, research has shown that annual reviews are very inefficient. They bring no benefit to health, at least for the majority of the healthy population.
But try to convince doctors who have spent years doing these tests – often by reserving 30-minute time slots for their patients and believing they are providing valuable service – to move away from this equally entrenched practice. obsolete.
Studies of the complexity of unlearning among physicians highlight the shame and loss of professional self-esteem that occurs when past practices are abandoned and considered obsolete.
The impact of eliminating old practices is even more powerful in patients. Our culture places a strong emphasis on the "more is better" mantra. Exams, tests and procedures abound.
When doctors refuse to provide care that was previously considered beneficial and important, the response of patients may be strong. As a family doctor, I often tell my patients that I do not do an annual check-up. Most are surprised and some are upset. I would be lying if I said that I did not think about complying with patients' requirements to comfort them and make my job easier.
To further complicate the situation, the overuse of health services allows physicians to protect themselves from malpractice lawsuits. This is called "defensive medicine".
Clinical judgment and reasoning are increasingly being replaced by algorithms. The lack of tests and interventions is increasingly difficult to justify.
But the cost of defensive medicine is incredible. On average, the US health care system spends $ 46 billion on care that has no other purpose than to prevent medical liability.
Aspirin is not the best option
Initiatives such as the Choosing Wisely international campaign strive to put a stop to low value-added care by educating medical staff and patients about the disadvantages of testing abuse.
The campaign has published lists of low value-added products specific to each medical specialty. It aims to break the culture "that's how it's always been done", dominant in medicine.
Yet, despite the launch of the campaign in 2012, physicians' practice habits have changed little.
While it is clear that for many average-risk patients, aspirin is not the best option to prevent heart attacks, it will be difficult to convince patients, physicians and healthcare administrators to the same thing.
The process of unlearning and disengaging old practices is hindered by a complex mix of emotions, individual expectations, legal responsibility, organizational structure and simple inertia.