Too much medicine; too little care
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4247 (Published 02 July 2013) Cite this as: BMJ 2013;347:f4247
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In relation to my posts re: blood sugar obsessions...
This is the actual clinical trial as published in the NEJM:
http://www.nejm.org/doi/full/10.1056/NEJMoa1307684
This is how it was reported by investigators and doctors to media:
http://www.clinicalendocrinologynews.com/single-view/saxagliptin-aloglip...
This meme shows how I see it.
Competing interests: No competing interests
The editorial by Glasziou and colleagues raises concern that the laudable aim for the transition of medicine from the treatment of disease to the prevention of its occurence could be harmed by the thrust of the Too Much Medicine series.1 The editorial opens the subject of overdiagnosis in general, and discusses the dual harms of treatment and patient anxiety which increase as diagnostic parameters shift in illnesses such as hypertension, high cholesterol, diabetes and osteoporosis. This is a one-sided view which makes no mention of the benefits for patients of primary prevention, which is only possible due to the early detection of risk factors before they become apparent, for example when a patient presents with central crushing chest pain. Cardiovascular disease was described in 2009 by the World Health Organisation as the number one cause of death world wide.2 Primary prevention by modification of multiple risk factors including hypertension and raised cholesterol reduces incidence of cardiovascular disease.3
While in certain areas, such as the unnecessary treatment of incidentally found PE, there should be an evaluation of medicine's increasing tendency to uncover and treat parameters which fall out of the normal range before they cause problems, if indeed problems are to arise at all, in other areas the strategy of investigation and treatment for known risk factors has been proven to be effective, and is not "Too Much Medicine".4
1. Glasziou P, Moynihan R, Richards T, Godlee F. Too much medicine; too little care. BMJ 2013;347;f4247
2. Mathers CD, Boerma T, Ma Fat D. Global and regional causes of death. Br Med Bull. 2009;92:7-32.
3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80% BMJ. 2003;13(7404):1419.
4. Wiener RS, Schwartz LM, Woloshin S. When a test is too good. BMJ 2013;347:f3368.
Competing interests: No competing interests
Too much medicine, too little care – editorial 6th July 2013
Professor Glasziou and his colleagues rightly suggest that investigation should be selective and targeted, yet it feels as though we are increasingly employing a scattergun approach to investigations across all fields. Whilst ‘overdiagnosis’ is currectly identified as problematic, surely this is a direct consequence of over 'investigation'. From serial CRPs, to myeloma screens through to full body scans our approach to the patient is increasingly weighted towards, if not reliant upon investigation, while the value of a thorough history and the art of clinical examination is increasingly being neglected. If this is indeed the case nationwide, (as is our belief), then some timely reflection is needed to establish why this is happening. Our own reflections and discussions with colleagues have raised three potential contributing factors;
Problem based learning is now integrated in most medical schools and with it comes a change in mindset and indeed the medical practice of junior and future colleagues. Issues have been raised to this effect by educationalists and a major concern is that patients are being seen as ‘presenting complaints’ and managed with a formulaic work-up. The corollary of all of this is ‘over-investigating’, over-diagnosing (and over spending).1
Secondly the climate of litigation has made clinicians increasingly fall back on unnecessary investigation and is impacting on our practice habits.2 Defensive medicine coupled with all-encompassing protocols drive up the investigation list in any given casualty department, acute medical unit, hospital ward or general practice.
Finally we witness how the European work time directives have affected junior doctor working patterns and continuity of care is often compromised. Patients on an acute ward may well see different doctors every day, who are then more likely to order a battery of tests as a fire-fighting mentality ensues. An interesting study demonstrates how this lack of continuity of care translates into doctors ordering investigations on patients they have never seen, (let alone considered the merit of the ordered investigation).3
There are of course other factors to consider and at greater length, but we feel that there is a trend that needs to be addressed; our investigating patterns are becoming robotic rather than considered and the care we provide often exhaustive rather than holistic. The ramifications of this will, we expect, continue to be highlighted in your current series on unnecessary care.
Department of Medicine for the Elderly
Dr Samad Samadian, Consultant Physician,
Dr A Farhat, GPST2
St Helier Hospital, Wrythe Lane, Carshalton, SM5 1AA
1. Paul A. Kirschner , John Sweller & Richard E. Clark (2006): Why Minimal Guidance During Instruction Does Not Work: An Analysis of the Failure of Constructivist, Discovery, Problem-Based, Experiential, and Inquiry-Based Teaching,Educational Psychologist, 41:2, 75-86
2. Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293(21):2609–17.
3. Bosanquet D, Cho J, Williams N, Gower D, Thomas KG, Lewis M. Requesting radiological investigations - do junior doctors know their patients? A cross-sectional survey. JRSM Short Rep. 2013 Jan;4(1):3.
Competing interests: No competing interests
There has been a barrage of diabetes articles recently. I just feel so bad for the type 2 diabetics who don't get the real story, the unbiased interpretation of the evidence.
Just try reading this online article from the BBC news, information provided by Diabetes UK. http://mobile.bbc.co.uk/news/health-23291410
It maybe true that diabetics get diabetic kidney disease, but it may not be so true that detecting the condition earlier will make a lot of difference except make the patient worry earlier.
And I quote from Barbara Young of Diabetes UK, as written on the BBC news article (link above), making a comment on "urine check" for detecting kidney disease in diabetics:
"All those people who are not getting this check are at increased risk of needing dialysis and ultimately of dying early."
Competing interests: No competing interests
A timely series, so well done the BMJ. My own concern is not of any fellow doctors over-investigating, but of the rise of commercial high st 'mole checking' shops, equipped with a machine to photograph moles and possibly a nurse to run the machine. If this considers the mole suspicious, customers are given a print out and advised to see their GP and request referral to a dermatologist. None of this has been tested for sensitivity, specificity, predictive value or any of the other essentials for a screening test that we would use in medicine. It takes a brave GP to ignore an official looking print out saying that this person should be referred. I am seeing an increasing number of these patients in my clinic, but have yet to find a melanoma. This all puts an increased demand on our already stretched service and carries all the potential downsides of over-investigation and unnecessary biopsies; but I suspect a good commercial proposition.
Competing interests: No competing interests
It is actually difficult to think of a condition where overdiagnosis is not a potential problem, since most medical diagnoses represent arbitrary points of change in definition along a spectrum of biological variables. People may move backwards and forwards along this spectrum, moving in and out of disease categories. In general practice, asthma, Type 2 diabetes, mental health problems and hypertension (really a risk factor rather than a disease) spring to mind.
I quite agree with my colleagues Julian Treadwell and Kevin Barraclough that we are subjected to the tyranny of the expert guideline. These are written by those whose livelihoods depend on making their own particular interest an industry for the rest of us. They are used as standards against which we are judged, and they drive the problem of overdiagnosis forward.
The whole issue of too much medicine and overdiagnosis is a huge issue that causes a colossal and tragic waste of resources at a time of financial crisis, yet it appears to be completely ignored by the politicians and NHS establishment. Congratulations must go to the BMJ to raising our awareness of this. When it comes to discussions about how to reform the NHS it is not so much the elephant in the room as the brontosaurus.
Competing interests: No competing interests
In their presentation of the BMJ’s Too Much Medicine campaign, Paul Glasziou and colleagues welcome suggestions for future articles. I suggest saving from oblivion studies of the use of ultrasound scans in pregnancy. Studies contrasting routine and selective attitudes came to the concordant conclusion that a politics of ultrasound scans “on demand” is a way to significantly reduce the average number of scans per pregnancy without altering the perinatal morbidity and mortality rates.1,2 We must keep in mind that routine ultrasound scanning in pregnancy is the most expensive component of modern prenatal care.
1. Ewigman BG, Crane JP, Frigoletto FD, et al. Effect of prenatal ultrasound screening on perinatal outcome. N Engl J Med 1993; 329(12): 821-7
2. Bucher HC, Schmidt J G. Does routine ultrasound scanning improve outcome in pregnancy? Meta-analysis of various outcome measures. BMJ 1993; 307(6895): 13-7.
Competing interests: No competing interests
Glasziou et al’s editorial “Too much medicine; too little care” suggests we ask the questions “Does this new test detect more or earlier ‘disease’? Do we understand the course of disease in these extra cases?” This immediately brought to mind concerns I have had for some time regarding “a new touch screen test for dementia.” CANTABmobile is a computer-based tool that has been widely promoted to the NHS as by the commercial company Cambridge Cognition(1). Along with IXICO, a commercial brain-imaging company, Cambridge Cognition received a grant from the Government-funded Biomedical Catalyst to provide an“early diagnosis service with the potential to provide a paradigm shift in diagnosis and care(2).”
Cambridge Cognition has, independently of IXICO, promoted CANTABmobile to primary care services across the UK. This is where my concern lies.
I am fully behind scientific innovation; however it was misleading to widely promote this test to primary care as a 5-7 minute “test for dementia.” Given this test was being “piloted” in NHS Forth Valley, and in a practice in my catchment area, I wrote to Cambridge Cognition on the 27th November 2012 outlining various concerns that I had about their promotional claim. In particular I asked for the evidence behind the headline claim that this was a “test for dementia” and whether the company envisaged any potential harms associated with it(3).
CANTABmobile is an isolated test of Paired Associates Learning (PAL) test and measures visual episodic memory. Visual paired-learning is useful in the assessment of patients presenting with memory problems, but in isolation cannot diagnose dementia. Reading the FAQ provided by Cambridge Cognition it is rather easy to get confused and come away with the understanding that used alone CANTABmobile is a test which is sensitive for “mild to moderate Alzheimer’s disease.” Cambridge Cognition does not mention in their promotional material that only 5-10% of those who get an amber or red light on their test will progress, over the following year, to dementia. The objective scientific reality is that even after five years, at the very most, only 50% of this group will ever develop dementia. The harm caused by this overdiagnosis has been ignored(4), and this seams to be particularly unbalanced when Cambridge Cognition have promoted CANTABmobile as a useful tool of reassurance for the worried well.
I note that, since I wrote to Cambridge Cognition, the marketing has been changed to “a new touchscreen test for memory impairment” (see screenshots). This was not before I saw patients referred to me on the basis of the original claim.
At a recent meeting on the Timely diagnosis of dementia on the 5th June 2013 Prof Sube Banerjee has been quoted on early diagnosis as saying: that it is “crucial to end toxic uncertainty for both patient and family(5)” but surely it is equally valid to be worried about the toxic certainty of an isolated test that is promoted misleadingly and avoids discussion of uncertainty and harm(6)?
(1) Homepage for CANTABmobile http://www.cantabmobile.com/
(2) Business Weekly, Cambridge Cognition in £15 million aim IPO http://www.businessweekly.co.uk/biomedtech-/15199-cambridge-cognition-in...
(3) Gordon, P. Letters sent to Cambridge Cognition on CANTABmobile and replies received http://holeousia.wordpress.com/category/medical-writings/dementia/cantab...
(4) Fox, C., Lafortune, L., Boustani, M., & Brayne, C. The pros and cons of early diagnosis in dementia. British Journal of General Practice, Volume 63, Number 612, July 2013 , pp. e510-e512(3)
(5) Banarjee, S. as quoted in “Timely diagnosis of dementia: a personal overview from carer Ming Ho of a meeting held at the King’s Fund, 5 June 2013 http://www.dementiauk.org/assets/files/what_we_do/uniting_carers/11_June...
(6) Strech, D. et al The full spectrum of ethical issues in dementia care: systematic qualitative review. BJP June 2013 202:400-406
Competing interests: No competing interests
I fully agree that Overdiagnosis and Overtreatment is a manifest danger in the modern NHS - screening by PSA for prostate Cancer, or Ultrasound for Aortic Aneurysm being egregious examples.
But this will require much more precise definition of terms.. The article states that Overdiagnosis should be suspected if "The incidence is increasing while mortality stays the same", and elsewhere refers to 'death rate'.
"One striking example is the tripling of the incidence of thyroid cancer in the United States, Australia, and elsewhere between 1975 and 2012,2 3 during which time the death rate did not change. This dramatic rise is best explained by increased testing and improved diagnostic tools, rather than a real change in cancer incidence. "
This example might indicate overdiagnosis , if death rate referred to the whole population. A case-specific death rate which remained the same would suggest that true disease incidence was indeed increasing, or worse, that 'benign cases' were increasingly detected, and then actively harmed by treatment !!
The Australian Cancer experience cited gives prevalence, incidence, and 'death rate' a more thorough examination
Competing interests: No competing interests
Re: Too much medicine; too little care
Another dpp4 inhibitor or gliptin news bit:
(from medscape article http://www.medscape.com/viewarticle/811716)
"Not only do diabetologists, along with cardiologists, need to take heart failure seriously in patients with diabetes, but the regulators do as well," Dr John J McMurray (University of Glasgow, Scotland) urged the audience. "We need to make heart failure a much more prominent component of our clinical trials, and we must not see major journals publishing major CV-outcomes trials in diabetes and not even mentioning one of the most important — if not the most important — cardiovascular complication of diabetes, which is heart failure."
and my meme.
Competing interests: No competing interests