What is required in the practice of breastfeeding medicine if we're to minimise overmedicalisation, paramedicalisation, and overtreatment?

"Driven by commercialism, direct-to-consumer advertising, and the pursuit of perfect health — a culture of “more is better” — modern medicine has fostered a culture of overdiagnosis and overtreatment. To avoid this harmful approach, clinicians should remain alert to commercial and social influences and practice shared decision-making, balancing patient values with evidence-based disease thresholds." Tikkinen 2025

Addressing overtreatment requires a multi-faceted approach

It is widely acknowledge that much health care is wasteful and low value, and this may be increasing, including in low and middle income countries.(11) This will require a whole of system approach, with macro (government), meso (organisational) and micro (individual) level elements.

Overdiagnosis and overtreatment are issues that must be understood as a consequence of the organisational, financial, and cultural attributes of the system.5,8 Low value care is often driven by uncertainty, disagreement on what not to do, the desire to do something for the patient, and perceived pressure from patients. Research on de-implementation of low value care has shown that multicomponent interventions hold the greatest potential for success.

In this article, I explore some of the multicomponent interventions those investigating this problem propose for minimising overmedicalisation, paramedicalisation, and overtreatments, adapting these considerations to the field of breastfeeding medicine.

In 2022 the Editor in Chief of the BMJ called for a health system reset to support the campaign against too much medicine.19 Those concerned with health system reform and the reduction of low value care agree that addressing overtreatment requires a multi-faceted approach that involves healthcare professionals, patients, and policymakers. 16

If reducing ineffective services is a priority, the ineffective service should be “de-implemented.”27 However, the complexities of de-implementation require

• Political will, including to increase regulations of private health insurance companies, and

• A willingness to invest in innovation and research.20

For example, I've held the view that in the field of breastfeeding medicine, addressing ineffective services requires

• Replacement of ineffective interventions with more effective interventions. This is what I've aimed to contribute towards with the development of the gestalt method of fit and hold, and the NDC clinical guidelines, for example.

• Addressing the serious international problem of ideologically-driven skewing of education of breastfeeding medicine physicians and IBCLCs because of the cancelling of the work of world-leading researchers by single-issue breastfeeding non-profits.

Armstrong et al propose that on the micro level, individual clinicians can demonstrate local leadership by recognising the footprint of low value care and refusing to provide it, acting as a role model to those around them.8

A rethink of evidence-based medicine and the nature of implementation science is required to better focus on patient-centred care and complexity

Armstrong 2017 argues that ‘openness about uncertainty of the evidence’ is an important step to take in reducing overdiagnosis.

Offering an agenda for the evidence-based medicine movement’s renaissance, Greenhalgh et al focus on the provision of clinically usable evidence, which can be combined with context and professional expertise so that individual patients can work collaboratively with their provider to receive optimal treatment. these authors propose that a rethink of evidence-based medicine and the nature of implementation science is required to better focus on patient-centred care and complexity.

In breastfeeding medicine, this requires significant change, including distinguishing between theoretical models and clinical translations. Currently a great deal of what's taught in breastfeeding medicine as fact and evidence-based clinical guideline is actually based upon contestable theories. This becomes acutely problematic for the wellbeing of mothers and babies when large parts of the intellectual community (researchers and educators) are blacklisted and closed out of intellectual discussion and rigorous debate.

The generalist doctor and leadership

Breastfeeding medicine is currently strongly influenced by leading USA breast surgeons, who have contributed important clinical insight and strategies, but who also apply the more reductionist breast surgeons lens, introducing various contestable diagnoses which tend to be accepted internationally without scrutiny (other than here).

Treadwell & McCartney wrote in 2016 that "doctors with responsibility for one condition may not have the generalist, holistic overview needed to help the patient sort valuable interventions from low-value ones.’ This may require a more assertive generalism than perhaps we are used to. We need to stand up and shape the clinical agenda from our unique perspective, drawing on the work and resources of academic primary care and the evidence-based medicine world.” 6

As a generalist doctor and researcher in breastfeeding medicine, I invite my generalist colleagues to respond to Treadwell & McCartney's call as we advance our field.

There are calls for generalist doctors and other primary care practitioners to lead challenges to low value care, because of the breadth of perspective, capacity to manage uncertainty, and interdisciplinarity of the general practitioner cognitive lens and training. 6 GPs have also been shown to be good diagnostic stewards, for example in the changes in prescribing of anti-secretory medications for infant reflux and antibiotics for colds and otitis media.

Moreover, multi-disciplinary teams that are co-ordinated by GPs have been demonstrated to be more cost-effective and effective.

"To ensure guidelines are evidence-based, practical, and sustainable, panels should include not only experts from narrow sub-specialties but also generalists, primary care physicians, and other health care professionals who likely better understand real-world constraints." Tikkenen et al 2025

At the micro level, individual clinicians can demonstrate local leadership by recognising the footprint of low value care and refusing to provide it, acting as a role model to those around them.

Education of both patients and health professionals about potential harms of low value care

Brownlee and Korenstein 2021 propose that there are two main tasks for the prevention of overuse of low value health care:

• Calculating the financial health system waste, and

• Understanding the scope of preventable harm.

In the field of breastfeeding medicine, this includes considerations of the financial and psychological burden of exacerbation of parental anxiety in the context of overdiagnosis, overmedicalisation, and low value care. Elevated anxiety predisposes to postnatal depression.

Self-reflective awareness by clinicians of our cognitive biases (Scott 2017)

Scott proposes that clinicians need awareness and understanding of how we structure knowledge and solve problems, and how these processes can be subverted by traditions, beliefs, rituals and feelings.17

"Many environmental facors relating to the financing and organisation of the healthcare system and the social and political contexts in which we work synergise with cognitive biases."

"Cognitive biases are not sins but by-products of the human need to make quick and efficient decisions in mentally demanding situations, but which can lead to suboptimal decisions."

Self-awareness of cognitive bias "requires information gathering, interdisciplinary liaison, considered judgement and force of personality that can be difficult to sustain in the face of traditional medical hierarchiesk professional silos and poorly connected clinical information systems. Second are current financial and reputation incentives."

Brownlee et al 2017 note that "growth of the ‘audit society’ is argued to have led to the development of regulatory cultures and new forms of bureaucracy within medicine which prioritise codified knowledge." 5

Morris et al 2025 observe that: "Clinical decisions can be subject to cognitive biases which lead to delivery of care of low value at odds with scientific evidence of best practice.12 Paediatricisn make decisions with varying levels of confidence and rely a lot on pattern recognition, simple rules of thumb or heuristics, tacit knowledge and habit. These have evolved in large part form personal experience and training, peer opinions and social norms. This intuitive, system thinking can be subject to biases which generate suboptimal decisions at odds with scientific evidence. This may result in provision of low value care to some." 12

References

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