Evidence for overuse of medical services around the world.

Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.

The importance of values in evidence-based medicine.

BACKGROUND: Evidence-based medicine (EBM) has always required integration of patient values with 'best' clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored. DISCUSSION: In this paper, we address this gap by demonstrating how a consideration of values can enhance every aspect of EBM, including: prioritizing which tests and treatments to investigate, selecting research designs and methods, assessing effectiveness and efficiency, supporting patient choice and taking account of the limited time and resources available to busy clinicians. Since values are integral to the practice of EBM, it follows that the highest standards of EBM require values to be made explicit, systematically explored, and integrated into decision making. Through 'values based' approaches, EBM's connection to the humanitarian principles upon which it was founded will be strengthened.

Primary care priorities in addressing health equity: summary of the WONCA 2013 health equity workshop.

BACKGROUND: Research consistently shows that gaps in health and health care persist, and are even widening. While the strength of a country's primary health care system and its primary care attributes significantly improves populations' health and reduces inequity (differences in health and health care that are unfair and unjust), many areas, such as inequity reduction through the provision of health promotion and preventive services, are not explicitly addressed by general practice. Substantiating the role of primary care in reducing inequity as well as establishing educational training programs geared towards health inequity reduction and improvement of the health and health care of underserved populations are needed. METHODS: This paper summarizes the work performed at the World WONCA (World Organization of National Colleges and Academies of Family Medicine) 2013 Meetings' Health Equity Workshop which aimed to explore how a better understanding of health inequities could enable primary care providers (PCPs)/general practitioners (GPs) to adopt strategies that could improve health outcomes through the delivery of primary health care. It explored the development of a health equity curriculum and opened a discussion on the future and potential impact of health equity training among GPs. RESULTS: A survey completed by workshop participants on the current and expected levels of primary care participation in various inequity reduction activities showed that promoting access (availability and coverage) to primary care services was the most important priority. Assessment of the gaps between current and preferred priorities showed that to bridge expectations and actual performance, the following should be the focus of governments and health care systems: forming cross-national collaborations; incorporating health equity and cultural competency training in medical education; and, engaging in initiation of advocacy programs that involve major stakeholders in equity promotion policy making as well as promoting research on health equity. CONCLUSIONS: This workshop formed the basis for the establishment of WONCA's Health Equity Special Interest Group, set up in early 2014, aiming to bring the essential experience, skills and perspective of interested GPs around the world to address differences in health that are unfair, unjust, unnecessary but avoidable.

The Role of Anger in Motivating Leadership.

As doctors, we see every working day the pervasive effects of different forms of structural violence and discrimination that undermine the hopes and aspirations of those on the losing side. This leads to powerlessness, fear and anger. Anger is not only forward facing but also directed toward, systems, institutions, governments-rather than individuals. At its best it is a protest against the status quo. We point out that leadership is one of the core values of our professionalism. In the light of what we see and hear, we have a responsibility to use the anger that this engenders within us to speak truth to power: this speaking is leadership. Our message is: feel the fear and the anger, use it to change the world, and enfold leadership in hope and the pursuit of justice.

On the irreducible individuality of the person and the fullness of life: simon gray's smoking diaries.

This article aims to challenge and expand notions of health, health care and health promotion, particularly in relation to smoking, via a consideration of the autobiographical literary work of the English playwright, Simon Gray. Gray died in 2008, having written a series of reflective autobiographical books, The Smoking Diaries. Gray was a lifelong smoker, perpetually trying to give up his habit. This article introduces Gray's diaries and their reflections on life, death, health care and smoking. It then enquires what can be learned about contemporary health care practices and assumptions from Gray's work. Finally, it reflects on the limits of views of health and health promotion when considered in the light of a fully lived life. In the life under consideration, health care risks are very differently understood to those prevalent in the medical community. Literary approaches to thinking about smoking are thus seen to place health and health care in broader, richer, and less instrumental perspectives than those that are common amongst contemporary health professionals and institutions.

The missing person: The outcome of the rule-based totalitarianism of too much contemporary healthcare.

OBJECTIVES: Medicine has an obsession with scientific progress and a misplaced belief in the perfectibility of the human body and mind and, as a result, there seems never to be time for the necessary backward glance. If we in healthcare are to learn any of the lessons of history, it seems important that we pay attention to those who have suffered at the sharp end of historical events. METHODS AND RESULTS: This paper invokes thinkers and writers who lived lives scarred by totalitarian politics. Their testimony emphasises the importance of paying attention to the particularity of individual experience and demonstrates the importance of story, listening, seeing, imagination, and attention. CONCLUSION: If we are to resist the secular totalitarianism of contemporary healthcare and reinstate the missing person at the centre of what we do, we as healthcare professionals must find the courage to disregard the rules. PRACTICE IMPLICATIONS: In every consultation it is important to be aware of the wider historical, political and social context that may direct and constrain the choices available to both patients and professionals.