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Debrief: Deprescribing Is Just the First Step

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Debrief: Deprescribing Is Just the First Step Life & Times Debrief it in full.2 Overprescribing and overdiagnosis Deprescribing is just the are obvious medicalisation but Illich argued first step that even the lifestyle discussions we offer to patients are a cultural iatrogenesis. It often The deprescribing trend. Deprescribing is a feeds into an ‘automedicalisation’ where niche that is coming into its own. Research people are then exhorted to self-monitor, seems to be bubbling up everywhere that’s check their own BP, constantly fretting about about reducing medications. As a ready their wellbeing. He stated: ‘Medicalisation reckoner, I did a quick search on PubMed occurs whenever some aspect of ordinary, for articles mentioning ‘deprescribing’. There everyday life comes to be so defined that were just 37 articles in 2015 but it had risen to it requires input from an institutionalised 182 in 2018. At the end of October 2019, there medical system’ and whenever we medicalise, were over 200 and it is rising quickly. This so Illich would have it, then we cause harm. could all be down to the popularisation of the And, there are no better examples of Illich’s term but I believe it’s a marker of the medical cultural iatrogenesis than the vogue for non- profession’s ennui — we’re heartsick of the pharmaceutical prescribing. guideline-driven industrialisation of medicine. “We need, as Richard There is a lurking discontent about the harm Extending deprescribing. It should provoke Smith put it in 2001, to rip we’re doing to people with medications a wave of revulsion when normal activities of and we’re rowing back. Deprescribing is a human life are offered on a notional FP10 as a up the ‘bogus contract’ reaction. prescription. If we really want to demedicalise with patients, accept that Medicalisation is much discussed but then the answer is obvious: doctors shouldn’t who would dare suggest we’re making be involved at all. Lifestyle medicine gurus, pain, illness, and death do much progress in the profession? Research wellbeing practitioners, and complementary happen and we often have suggests ever more medical conditions practitioners should hold off on their cheers and more indications for treatment. Various — Illich was just as damning, also regarding a limited ability to manage organisations, sometimes framed as them as medicalisation, promoting ‘at least as them.” overdiagnosis groups, have pushed back, much dependence as a medicalising general though, paradoxically, they swing the sword practitioner’. of evidence to demand fewer diagnoses and In the past week alone, I’ve read articles medicines. It’s worthy, though there is a risk that have stated doctors should start issuing that overdiagnosis movements prioritise the nature-based prescriptions to get people problems of the privileged — after all, you to spend more time beside the ocean; and have to have contact with the healthcare we should prescribe singing for various profession to have a diagnosis and even in the mental ailments. And, of course, there is UK, never mind the poorest countries in the the daddy of them all: social prescribing. We world, our most vulnerable populations are are medicalising conversation, medicalising underserved. As so often, it feels like we need walks on the beach, medicalising even the a redistribution of our efforts. simple pleasure of singing. We need, as Richard Smith put it in 2001, to rip up the Illich and cultural iatrogenesis. It was the ‘bogus contract’ with patients, accept that social philosopher, Ivan Illich, in his book pain, illness, and death do happen and we Limits to Medicine that lit up the debate often have a limited ability to manage them.3 on medicalisation when it was published in We certainly need to reduce unnecessary 1976.1 Illich was writing before the 1980s and drug prescriptions but perhaps the more the free-market medico-industrial machinery honest relationship with patients he clamped us in its jaws. The writing is, recommends needs an extended, purer, form unsurprisingly, dated in places, but more often of ‘deprescribing’. We can’t undo the harms it’s deeply prescient and Illich’s comments of medicalisation by medicalising every facet and predictions are more salient than ever. of human life. A simple step would be to stop REFERENCES He is quick to highlight the same point as using language that implies every human 1. Illich I. Limits To Medicine. Medical Nemesis: the overdiagnosis groups — that ‘most of activity can be offered on a prescription. Now The Expropriation of Health. London: Penguin today’s skyrocketing medical expenditures that would be deprescribing. Books Ltd, 1976. are destined for the kind of diagnosis and 2. Illich I. Medicalization and primary care. J R treatment whose effectiveness at best Euan Lawson, Coll Gen Pract 1982; 32(241): 463–470. is doubtful’. Illich gave a potted summary Deputy Editor, BJGP. 3. Smith R. Why are doctors so unhappy? BMJ when he lectured the 1982 RCGP Spring Email: [email protected] 2001; 322(7294): 1073–1074. General Meeting and the BJGP published DOI: https://doi.org/10.3399/bjgp19X706757 606 British Journal of General Practice, December 2019.
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