Are doctors being crushed by busywork, so they don’t get much time to actually help people? If you read no further, that’s the crux of my argument.
Friends ask if I have a family doctor. I admit that Dr. C. has been my doctor for two decades. He inherited me after my old school doc retired. While they think I’m lucky, frankly he’s a peripheral person in my life.
Over 20 years I’ve seen him maybe once a year in very short consultations, (usually for an X-ray requisition to see if I broke something after falling off my bike). In each visit I have noticed a certain tendency: that he wants to give me a lot more than I’m into. He wonders about my cholesterol or my blood sugars, a colon test, a prostate check, or a flu shot. I’m polite. Each time I say, I’ll look into those things and get back to him.
I never do. Why? Because I’ve already looked into those things and there’s basically nothing of interest there. I’m a healthy, fit, 60ish guy who has spent 30 years studying the value of medical technologies, pharmaceuticals, and screening tests and the preventative prizes he’s offering are theoretically fine, but in my view of things they are little more than meddling ways to turn healthy people into patients. Sure, call me a skeptic but this sort of busywork is unlikely to contribute to the length and quality of my life. I’ve read most of the big studies of the major classes of pharmaceuticals and parsed the evidence on medical screening, enough to have written books on this stuff. I’m okay to refuse more medicine than I need.
Like most doctors, however, he’s just being proactive, seeking out signs of disease before it might hurt me. I get that. But it has me thinking: where does he find time to help people who are actually sick?
Here’s the blunt truth for health policymakers and others overzealous about prevention: if our doctors are overly occupied delivering low-value prevention in healthy people, they’re not going to be there for the genuinely sick. That’s not callousness. It’s basic resource allocation informed by evidence about benefits, harms, and opportunity costs.
Large trials and systematic reviews have repeatedly shown that most screening tests and preventive prescriptions yield marginal benefits for otherwise healthy individuals, while often introducing real harms. Screening that seems sensible on paper can lead to false positives, cascades of further testing, overdiagnosis, anxiety, and procedures that don’t improve — and sometimes worsen — the quality or length of our lives. Every drug comes with harm of some kind. Taking your chances with those harms if you are seriously in need, sure. But what if you’re already otherwise healthy?
Drugs prescribed for healthy people frequently have tiny benefits. Lower your cholesterol? Sure, if you think a 2% reduction in the risk of a heart attack for swallowing a daily pill for 10 years (and the possible increased risk of muscle weakening that comes with it) is worth it. An osteoporosis drug that produces a 1% reduction in the risk of a hip fracture? Then there is the problem with overdrugging older people, a particularly common form of cruelty in our elderly which results in a high rate of hospitalizations and deaths. Millions of otherwise healthy people get labeled “at risk,” exposed to drug adverse effects, and end up wasting our doctors’ time (and our health care dollars) that could be devoted to acute problems.
Like most doctors, Dr. C defaults to “prevention” because it’s neat, feels proactive, and aligns with performance metrics and billing incentives working in a system that rewards doing more rather than doing what’s most necessary. But is his time being stolen away from more urgent cases: the frail patient with multiple things going wrong at the same time, the person with new, unexplained symptoms, or the caregiver needing complex coordination for Mom who is failing fast? For those moments when we need experienced clinical judgment, continuity, and a doctor’s steady hand there never seems to be enough of our doctors’ time.
Policy should acknowledge two facts. First, prevention isn’t always good, or even worth the trouble. It’s really only beneficial when targeted to people at sufficiently high baseline risk where absolute benefit outweighs harm. Second, primary care capacity is finite. Feeding it with low-yield interventions constrains its ability to handle urgent and complex care.
What would a smarter approach look like? Our health systems need to create clear, evidence-based thresholds for when to recommend screening or primary prevention drugs — thresholds based on absolute risk, life expectancy, and patient values. Let’s ditch the obnoxious electronic medical prompts that push too much unnecessary testing on healthy people like me. That expensive busywork has to go. We can’t afford it.
Second, clinicians and the public need some honest education of harms and benefits that come with healthcare. Every visit to a specialist is not going to be the end of your problems. It just might be the beginning. The public needs to reject the “More prevention is better” propaganda and start questioning those selling them drugs and theories of “early treatment” that drive too much care in healthy people.
People will accuse me of being cold-hearted or “anti-preventive.” I’m neither. Prevention makes sense only when applied where it matters, not for whom the balance of benefits and harms is negligible. We can have both prevention and capacity — only if we put sick people back into the centre of our doctor’s care.
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