Communicator – Free Spirit

You have an urgent need to go to the toilet?

Talk about it with your doctor The billboard shows an audience of red armchairs, regularly interspersed with pretty white ceramic toilet bowls. Above, the title reads “You suffer from overactive bladder?” and a caption that respectfully recommends: “Talk about it with your doctor”. Signed by Pfizer. The background is an anonymous city street in Canton of Ticino. The photo was taken several years ago by Gianfranco Domenighetti, who sent it to me via e-mail for my presentations.

For many years I have been writing and speaking in public about medicalization, disease mongering, the health industry, changing and updating from time to time the examples as I collected them over time. As for this picture, however, it should be noticed that I am particularly fond of it, to the point that, even today, it is never missing from the set of slides I carry along, no matter if it is outdated and characterized by a “Swiss” elegance, a little bit inadequate compared to Italian taste. Actually, precisely for this reason, because an image showing bogs in the stalls never fails to raise a laughter, and consequently the benevolence of the public, which lower their reserves. And above all because it represents in a single image many things that Gianfranco, like an older brother, taught me over the twenty years or so during which we actually constituted, without ever formalizing it, a “travelling company” against the culture of excess in medicine and health.

Since the publication of his prodigious book “The Health Market”, I have learned from him that all the themes of critical thinking in medicine can also be communicated with irony, sarcasm and even with a sneer. I had studied drawing on the sacred texts of the seventies, — Michel Foucault, Ivan Illich, Petr Skrabanek and James McKormik, Thomas McKeown, etc. –, from which I distilled penetrating, yet serious analyzes, which would never have raised a smile in any reader or listener. Discovering that one could light-heartedly reveal a comic side even in doctors’ (and lawyers’) behaviour, for example when it came to deciding whether to have one’s own children operated on their tonsils or appendix, rather than other people’s, was a revelation I owe to Domenighetti at least as much as I am in debt to Jules Romains, the author of Knock, the triumph of medicine.

The billboard with the overactive bladder dates to about ten years ago, at a time when, with the partners of the PartecipaSalute project(Alessandro Liberati and Paola Mosconi), we were conducting a systematic analysis of how the so-called awareness campaigns on diseases (a crucial tool of disease mongering) were being planned and conducted, often on a global scale, together with the control on the definition of the border between health and illness and with the clinical research conducted as a marketing tool. Analyzing dozens of press releases on the most varied pathologies, we had succeeded in identifying a constant “rhetoric” structure of the topics, which is divided into four passages, which are still valid:

1. 1. to exaggerate the problem by affirming that it affects millions of people, mostly unaware;
   2. to arouse fears by inducing to believe that the risks are serious, especially in the absence of a prompt intervention;
   3.  to induce examinations and tests with the aim of creating potential patients/clients;
   4. to trivialize the solution, claiming that a new product can easily solve the problem;

The wording “Talk about it with your doctor” in the caption of Domenighetti’s photo is not only an excellent exemplification of point 3, the true pivot and engine of every medicalization intervention (because when you manage to convince a healthy person that he or she could be sick, and… Bob’s your uncle!), but, with the background of bogs in the stalls, it is also a cue for a liberating laugh, which lightens the critical discourse and makes it more easily understandable and acceptable. The “Domenighetti method”, which consists in punishing the bad marketing habits while smiling, has become over time a familiar lexicon among us, with continuous exchanges of more or less entertaining and instructive gems. As for example the “automatic generator of press releases” (http://www.partecipasalute.it/informati-bene/generatore-comunicati-002.php), which with a set of drop-down menus allows anyone to invent a disease, emphasizing its spread and risks, deprecating the ignorance existing about it and its underestimation, and finally disseminating its solution, even “patenting “ the name of the remedy using suffixes like -ab, -ib, -il, or -ox.

Roberto Satolli
medical doctor and journalist

“From an economic point of view, the health sector is probably the most important industry of large consumption of goods and services characterized by complexity, uncertainty, information asymmetry, poorly measurable quality, conflicts of interest and corruption, as well as by opacity and variability of decisions (in clinical, organizational, research and financing terms)”.

This is Gianfranco Domenighetti’s thought regarding the health sector, as has been repeatedly expressed in recent years, and in particular in his famous speech made at the conference held in memory of Alessandro Liberati at the Rizzoli institute in Bologna in December 2012, a speech that was then resumed in his blog by Richard Smith.

Among the negative characteristics, mention is made of the variability of decisions, a sign of lacking clinical appropriateness and excessive use of examinations and treatments. As early as 1993, Gianfranco had already shown that the “normal” population was subjected to surgery such as the removal of the tonsils, the uterus and of the gallbladder with a frequency of one and a half times or almost double compared to physicians, lawyers and their relatives, i.e. the most informed categories on the subject.

And Gianfranco was not short of subsequent examples of inadequacies and wastage; in this respect, he often remembered that only 11% of the approximately 3,000 treatments described by Clinical Evidence (2012) were proven effective, that in the USA the estimate amount of services of no benefit to patients corresponded to at least 30% of the total health expenditure (Brody 2012), and that, for example, 50% of angioplasties in patients with stable angina were inappropriate (JAMA 2011).

Gianfranco’s style was characterized by rigour in researching and presenting data and by a great lucidity of thought. He presented data from the OECD for Italy, which showed that the use of CAT scans, MRI scans, Caesarean sections and antibiotics was among the highest in the world and, on the contrary, the expense for elderly and long-term patients as well as for the provision of nurses was among the lowest. Deducing therefrom that “Italy seems to have favoured a health system where resources (and therefore priorities) have been destined above all to a super equipment of cutting-edge technologies and specialized services, often useless and underused in addition to involving inadequacies, to the detriment of availability of staff, services and facilities for personal care, particularly for non-self-sufficient and chronic patients”.

For Gianfranco, there are many factors underlying the lack of appropriateness, which represent as many obstacles for the initiatives that try to promote it. Firstly, the information asymmetry between professionals and “normal” citizens, which involves the dominant doctor-patient relationship being still paternalistic, in which the patient, have no technical knowledge, slavishly follows the doctor’s recommendations and is led to overestimate the benefits of screening, diagnostic tests, drugs and other treatments as well as underestimating related risks.

Then there is the ubiquitous issue of conflicts of interest, which equally concerns the drug and medical device industry, which sponsors and influences most of the clinical research and training of professionals; doctors, who regularly receive visits of pharmaceutical informants; and, finally, the health organizations themselves, whether private or public, whose individual economic incentives (in particular, service-based remuneration) and company objectives bring about a multiplication of diagnostic and therapeutic services.

And yet, despite his “healthy scepticism”, Gianfranco looked with interest at the invitation made by Howard Brody in 2012 to doctors: specifically, to take on the responsibility for the proper use of resources, in the interest of their patients. Moreover, he saw a sign of possible change in the launch, again in 2012, of the Choosing Wisely initiative in the USA, promoted by the ABIM Foundation, a scientific association of doctors, in partnership with Consumers Reports, an independent consumers’ organization.

For the first time, professional societies in alliance with citizens published lists of tests and treatments often unnecessary, the “top 5 lists” that professionals and patients should speak about in order to question them. When a similar initiative was launched in Italy by Slow Medicine, the project “Doing more does not mean doing better – Choosing Wisely Italy”, Gianfranco was a staunch supporter of it, and promoted its diffusion both in Italy and in Canton of Ticino. At the same time, he clearly foreshadowed the potential obstacles that its practical application would have encountered both on the part of citizens and professionals, and supported the absolute necessity of conducting an assessment with regard to its actual impact. The path pointed out by Gianfranco Domenighetti, with his clarity and methodological rigour, is not an easy one, but it is the only way that health professionals are allowed to embark on by ethics and sense of responsibility.

Sandra Vernero M.D.

co-founder and vice-president of the Slow Medicine Association coordinator of the project “Doing more does not mean doing better – Choosing Wisely Italy”