Too Much Medicine: from evidence to actionBMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7141 (Published 04 December 2013) Cite this as: BMJ 2013;347:f7141
- Ray Moynihan, senior research fellow1,
- Carl Heneghan, professor of evidence based medicine2,
- Fiona Godlee, editor in chief3
- 1Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD 4229, Australia
- 2Centre for Evidence Based Medicine, University of Oxford, Oxford UK
- 3BMJ, London, UK
Well known for their debates about independence, the people of Quebec may soon attract global attention for their campaign to wind back the harms of too much medicine. Earlier this year, the Quebec Medical Association issued a position paper on overdiagnosis and overtreatment and created a working party to identify causes and develop solutions. In September, a delegation of the most influential people within Quebec’s health system—representatives of doctors, nurses, pharmacists, and hospital managers—attended the inaugural Preventing Overdiagnosis conference in Dartmouth, New Hampshire, United States.1 Now they’re busy building a knowledge base within the Canadian province around strategies to counter overdiagnosis and overtreatment.2 In Quebec, evidence is informing action.
At the same time, in the United States a group convened by the National Cancer Institute found that “overdiagnosis is common and occurs more frequently with cancer screening,” and it recommended that professionals and the public be better informed.3 This recommendation is reinforced by recent surveys suggesting that doctors inform fewer than one in 10 people about the risks of overdiagnosis and overtreatment with cancer screening.4 And, as the BMJ’s Too Much Medicine series is highlighting, the risk of overdiagnosis extends across a range of conditions, including pulmonary embolism,5 chronic kidney disease,6 and pre-dementia.7 Today the BMJ announces a call for research papers for a coming theme issue in 2014 on overdiagnosis and overtreatment (box 1).
Box 1 Preventing Overdiagnosis 2014 conference
The Preventing Overdiagnosis 2014 conference will take place on 15-17 September at the Centre for Evidence Based Medicine, University of Oxford. Further information including registration and abstract submission details are available at www.preventingoverdiagnosis.net. The BMJ is planning a theme issue on Too Much Medicine to coincide with the conference.
After more than 150 scientific presentations and posters, and the attendance of more than 320 people from almost 30 countries, the 2013 Preventing Overdiagnosis conference identified several key strategic priorities: enhancing the science; educating professionals and students; communicating to the public; combating perverse systematic incentives that transform people into patients, and reforming the way that diseases are defined and broadened (box 2).
Box 2 Preventing Overdiagnosis 2013 statement: strategic priorities
Strengthen the science of overdiagnosis, develop consensus around methods to measure the problem, and evaluate strategies to maximise benefits and minimise harms
Develop and incorporate education about overdiagnosis into standard clinical training for healthcare professionals and students
Advance strategies to inform the public and policy makers about the problem and find effective ways to communicate about what are often counterintuitive issues
Build on efforts in health systems around the world to reduce overdiagnosis and combat perverse incentives that turn too many people into patients unnecessarily. In particular, change how diseases are defined, by minimising professional and financial conflicts of interest among expert panels, and by rigorously assessing the benefits and harms of expanding disease definitions (www.preventingoverdiagnosis.net)
This week marks the opening of abstract submission and registration for the second international Preventing Overdiagnosis conference, this time to be hosted by the Centre for Evidence Based Medicine at the University of Oxford, over three days (15-17 September 2014), and again supported by the BMJ (www.preventingoverdiagnosis.net). Presentations and posters are sought on the nature and extent of the problem and potential responses to it. Although the science is central, there will also be time for debate about the wider context, and contributions from consumer and citizen advocates are encouraged: the US consumer organisation, Consumer Reports, is another conference partner.
Iona Heath, former president of the Royal College of General Practitioners’ and one of the keynote speakers at Oxford, recently pointed out that overdiagnosis and overtreatment have at least four serious ethical implications.8 They produce harm from unnecessary labelling, and broadening disease definitions waste resources that could be better spent on necessary treatment for the most severely affected. In addition, cost inflation undermines health systems based on solidarity, and intensifying biotechnical activity can marginalise and obscure the wider social and economic causes of disease. Another keynote speaker will be John Burn, genetics lead for the National Institute of Health Research, and former director of the Institute of Human Genetics. He will help explore the risks associated with the explosion in genetic testing—part of a wider trend towards much more readily available diagnostic and screening tests. Other keynote speakers include Jack Wennberg from the US, Linn Getz from Norway, and Alexandra Barratt from Australia.
Importantly, the emerging science of overdiagnosis is offered with humility, with ready recognition of the many benefits of medical diagnoses and much unmet need for treatment. Along with sound and robust data, some of the accruing evidence is tentative in nature, and the 2014 conference will debate the best ways to define and measure overdiagnosis. There is also a strong desire to place these contemporary concerns within historical and philosophical frameworks, and to forge links with other debates within medicine, including that around “shared decision making.” As those who attended the inaugural 2013 event in Dartmouth will remember, this conference offers a rare opportunity to meet and work with clinicians and researchers across a range of specialties, as well as people from policy and consumer circles.9
This current move to expose and combat the problem of medical excess is being driven in part by researchers steeped in the evidence informed approach to medicine. Bond University’s Centre for Research in Evidence-Based Practice has helped initiate this series of international scientific conferences, and now the University of Oxford’s Centre for Evidence Based Medicine will host the second of them. This underscores the fact that evidence is not produced and used in a value-free vacuum. Rather, it is generated, disseminated, and sometimes distorted by vested interests—both professional and commercial. For example, “evidence based” guidelines may sometimes contribute to overdiagnosis or overtreatment through the quality measures that enforce them,10 or through expanded disease definitions produced by heavily conflicted guideline panels.11 As attempts to wind back unnecessary medical excess intensify, some of those vested interests will no doubt fight back hard to defend their turf and their markets. And that’s another reason that we look forward to hearing how the people from Quebec are doing, when they report back on their local actions at the conference in Oxford next year.
Cite this as: BMJ 2013;347:f7141
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: RM and CH are members of the committee planning the scientific programme for the 2014 Preventing Overdiagnosis conference.
Provenance and peer review: Commissioned; not externally peer reviewed.