Eliminate the Unnecessary… Less is More

The medical profession is one of the few professions in the world where the person remains a student for life. We are perennially in this stage of learning some more …a bit more…a little more…And not surprisingly this ‘More’ seems to be a never ending process.But recently I have realised one startling truth to this phenomenon of ‘More’ and that is that the ‘More’ you learn the ‘Less’ you do. In other words as you grow in age and experience you realize that ‘Less is more’.

When I was a medical student and even when I was an internal medicine fellow, every patient that I attended to in the out-patient clinic never left empty handed. They had to be prescribed something. If nothing , they had to go with at least a prescription of Multivitamins. After all they had come to the doctor with the hope of being “treated”. Today as a qualified and practicing nephrologist, I realize that those unnecessary prescriptions of multivitamins were more an act of cowardice than practicing Medicine. I just didn’t have the guts to turn around and tell the patient that the common cold he had was just a self-limiting viral infection that would get cured irrespective of any intervention. And believe me I wasn’t alone. I had more than enough company. And the consolation given to our perennially overactive conscience was ‘At least the multivitamin did no harm’…or so we think.We still haven’t mustered the courage to practice minimalism. To do less.

In general, it is always easier to overdo than to stay calm and “underdo.” It is often easier to do something rather than nothing. The same holds true in Medicine. Recent literature questions the use of N-Acetyl cysteine (NAC) to prevent contrast induced nephropathy (CIN). The PRESERVE trial showed no benefit of oral NAC over placebo among patients with high risk for renal complications undergoing angiography. Actually we are questioning the existence of CIN itself. And yet I see the rampant use of NAC. This behaviour is justified by the same argument…”At least it does no harm”. Another example of this futile ’more’ treatment is the role of renal replacement therapy in the critically ill. The AKIKI study and the pilot phase of the STAART-AKI study presented evidence that can probably help us change our practice and safely say that ‘More dialysis’ in terms of early initiation had no added advantage. In this case it may actually cause harm. The use of plasmapheresis for a whole lot of renal diseases has a low quality evidence but we continue to use it in the face of the paucity of evidence. It’s time we question the use of unproven therapies and accept the probability that in addition to providing no benefit they may cause real harm to our patients. Apart from this we need to take into consideration all the literature that is already published and the evidence that keeps changing. We can’t keep ignoring these changes and continue to practice what we think is right.

Bob Dylan crooned long ago…”Then you better start swimmin, or you ll sink like a stone, For the times they are a-changin”. 

Today, is the time of evidence based medicine. Eminence based medicine is sinking like a stone.

The less is more paradigm is gaining popularity in the critical care speciality. Practices are evolving in the direction of minimalism with a preference for fewer interventions, shorter durations of treatment, less invasive monitoring, and decreased use of screening tests. Especially in the critically ill, we need to realise that the stress of an illness cause a lot of parameters to change beyond the normal range which may be protective. Trying to normalise each parameter may work contrary to two billion years of eukaryotic evolution that has endowed upon humans the complex but still poorly understood physiological adaptations that are part of the healing process. Just keep it simple…simplicity is the ultimate sophistication. However at the same time let’s not confuse the less attitude with a laid back attitude. If a male patient presented to my clinic with an urinary tract infection and I do not investigate for an underlying urinary tract abnormality, I am being laid back about the patient’s condition. Laid back is ignoring potentially reversible parameters which may affect the short and long term patient outcomes. However, if I refrain from using cranberry supplements, I have successfully practiced the less attitude. The less attitude stresses better focussed and well researched patient care and throws out unproven therapies which have been used out of habit rather than well reasoned medical science.

As Warren Buffett said, ’The chains of habit are too light to be felt, until they get too heavy to be broken’. 

The other pertinent question that needs to be asked is that what does a therapy do in terms of the ‘patient’s outcome’ apart from the primary outcome? The use of hydroxyl ethyl starch for fluid resuscitation (6S study) increased mortality in the treatment arm along with an adverse primary outcome. The use of ultrafiltration in decompensated heart failure with cardio-renal syndrome (CARRESS-HF study) showed similar mortality in both arms along with an adverse primary outcome. It makes little sense in using a therapy that gives similar, worse or better primary outcomes as compared to the control therapy when it does little to change the patient mortality or morbidity. In other words we need to demand randomised controlled trials that give us patient centric results (hard outcomes) rather than laboratory based or clinical parameter based results.

Medical science is ever changing and evolving. A judicious yet restrictive approach with avoidance of unproven therapies will simplify our care while simultaneously promote efficient resource utilisation. Newer evidences come in, older theories are rejected. We evolve and improve our thinking. We need to change our practices as we grow wiser. The need to do at least something must be replaced by the need to do what is necessary and proven.

We need to live as John Keynes suggested when he stated, ‘When the facts change, I change my mind…what do you do sir?’ 

Mayuri Trivedi
Nephrologist
PD Hinduja Hospital
Mumbai, India
NSMC Intern Class of 2018