“Less is More” – We Need to Think of the Patients First

Brevity is the soul of wit, says a Shakespearean quote. Yet, we always find ourselves elaborating on many things. Writing, and in particular, scientific writing, is one such art where it is necessary to be precise and brief. Journals often have word counts for their article types and so also, there are word limits for conference abstracts. Very often, we struggle to fit in our content within the specific word limit, much like the precis writing we had to do in school. But the result is often amazing, with the final version conveying all the necessary content. Elaborate writing is a universal problem, with many people finding it difficult to keep their manuscripts short. They try to retain every figure or table, not heeding the requirements of the journal. The result is that the manuscript loses much of its charm, and the meaning is often lost in the maze. “Keeping it simple” is an art. It is not just limited to scientific writing but can be extrapolated to every walk of life. It is exemplified by the “Less is more” aphorism, originally attributed to a 1855 poem by Robert Browning and later popularized by the 20th-century architect Ludwig Mies van der Rohe when he used it to describe the minimalist design of his buildings.[1] In Medicine, this concept took root only about 15 years ago. “Choosing Wisely” campaign was started in the US in 2012 by the American Board of Internal Medicine with the intention of creating awareness among the clinicians and the patients about the evidence base or lack of it, for some of the commonly prescribed tests, procedures and medications.[2] The campaign encourages specialty societies to create lists of tests and procedures that tend to be overused within each specialty.[3]Smarter medicine in Switzerland, the SMART medicine initiative in Italy, are examples of initiatives by the respective national societies, framed to reduce unnecessary low-value medical interventions.[4] In practice, however, the clinicians still find it difficult to follow this rule. Many doctors find it difficult to give concise prescriptions. The patients with chronic diseases such as chronic kidney disease (CKD), cardiovascular disease (CVD), and a host of other chronic conditions are often handed a prescription with a long list of medications. The result is that the patients frequently fail to adhere to their prescriptions. Studies point out that 40%–60% patients may be nonadherent to medications.[5] The financial burden is a major concern. In countries like India, where the treatment costs are not universally subsidized, many people belonging to the lower socioeconomic strata do not take the medications as prescribed due to the financial burden. It is to be noted that even in countries which provide near-universal health care, the systems find it difficult to sustain and face a huge financial burden. Studies point out that between 22% and 30% of all healthcare interventions can be considered potentially inappropriate.[4] The patients often dislike taking multiple medications which is another cause for nonadherence. The hazards of prescribing more medications also involve a higher chance of drug-drug interactions.[6] In addition, drugs may be prescribed unnecessarily, due to overdiagnosis of physiologic alterations as disease. This is particularly noteworthy in the case of kidney disease in the elderly, where they often get a diagnosis of CKD, while they may be just having a physiologic decline in kidney function.[7] Drug stewardship is especially important in patients with kidney disease as doses of drugs need to be tailored according to the estimated glomerular filtration rate to avoid adverse drug effects and acute kidney injury.[8] Informed decision-making by the patients is often lacking, and the physicians often do not discuss the pros and cons of multiple medications with the patients. The choice of medical interventions in the hospitals also lacks adequate adherence to available evidence. Antibiotic stewardship, which refers to the choice of appropriate antibiotics for infections, is not commonly followed.[9] Use of antibiotics for presumed viral infections, use of multiple antibiotics and incomplete evaluation of underlying anatomic or functional malfunctioning are common practices, and this has led to rampant antimicrobial resistance. Use of incomplete courses of antibiotics and inappropriate use of steroids or native medications of doubtful composition adds to the insult. Performing a standard protocol of investigation irrespective of the patient’s symptoms is also a rampant practice. Often this sparks more investigations, and the patient thus suffers from a multiplied burden of overdiagnosis, over-treatment and emotional trauma, in addition to prolonged hospital stay and added costs. Figure 1 lists some of the reasons for lengthy prescriptions and overuse of diagnostic techniques.Figure 1: Reasons for overdiagnosis and overtreatment. EBM: Evidence-based medicineThe concept of “Less is More” is also exemplified in Nephrology. In the field of kidney replacement therapies, “more” therapy is not beneficial, as evidenced in most studies. As early as 2010, there were studies conducted to look at early initiation versus late initiation of dialysis in CKD, and the trials did not show any survival advantage with early initiation of dialysis (IDEAL study).[10] In critically ill patients with severe acute kidney injury, the AKIKI study and the STAART-AKI study demonstrated that there was no significant mortality benefit with early dialysis, and the authors specifically recommended that a delayed strategy could even avoid the kidney replacement therapy.[11,12] Dialysis adequacy indicators have also evolved over the years, and studies have shown that achieving higher Kt/V than the recommended standard is not associated with better survival.[13] Dialysis adequacy depends on multiple factors and not only on small molecule clearance. Achieving a specified Kt/V may be especially difficult in the elderly and may even have deleterious consequences.[14] The role of high dose of erythropoiesis-stimulating agents (ESA) has also been disregarded, as several randomized controlled trials revealed that higher doses of ESAs were associated with unexpected thrombotic consequences and cardiovascular adverse events.[15] The newest argument against “more” treatment is the environmental concern. There are arguments against single use of dialyzers, and in favor of delaying dialysis, incremental dialysis and careful use of water, electricity and other resources which propose that “less is actually more.”[16] Studies point out that optimizing dialysate flow rates could significantly save water use in dialysis units without compromising dialysis delivery in young, hemodynamically stable patients.[17] Conservative Kidney Management is an evolving approach in the management of CKD patients that focuses on the quality of life and symptom management without dialysis or kidney transplantation, and also focuses on avoiding unnecessary KRT.[18] The elderly, the frail and patients with multiple comorbid conditions may not opt for dialysis as they approach end-stage kidney disease, and conventional dialysis may not give them better quality of life. The aggressive treatment of comorbid conditions such as cancers and CVDs has led to nephrologists dealing with complex situations, and this has only enhanced the chances of “more” treatment, about which we need to exercise caution. The improvements with predialysis CKD management and readily accessible, often subsidized dialysis have raised concerns of over-prescribing dialysis. Thus, it is imperative that the nephrology professionals carefully weigh the benefits and risks, taking the patients’ preferences into consideration and offer treatment. In the realm of Health Sciences, the principle of “Less is More” underscores the importance of thoughtful, evidence-based decision-making. By prioritizing patient-centered care and minimizing unnecessary interventions, we can reap multiple benefits. We can enhance patient outcomes, reduce healthcare costs, and mitigate the risks associated with overdiagnosis and overtreatment. It is crucial to ensure that every intervention is justified, beneficial, and aligned with the patient’s best interests. This may not only foster a more sustainable healthcare system but also uphold the fundamental ethos of medicine: Primum non nocere (to do no harm).