Role of fear in overdiagnosis and overtreatment—an essay by Iona Heath

As a junior doctor progressing through my foundation years, the fear of missing that crucial diagnosis and making a critical mistake has become more and more apparent to me. With the constant reminders from seniors, lectures from the defence unions and even e-learning modules about how to avoid being sued; it is hardly surprising that the fear of uncertainty is increasing. As the author suggests, this uncertainty is leading to the overinvestigation of the well patient, just in case we miss that one patient with a serious diagnosis.

As juniors, we are often reliant on policies and guidelines to aid our decision making and management plans and I think that this is having a big impact on our ability to manage those patients whose symptoms don't quite fit the patterns; again leading to multitudes of unnecessary and potentially invasive tests. These investigations may, in some cases, allay some of the fears and anxieties plaguing both the clinicians and the patients but also lead to overdiagnosis and overtreatment.

On many occasions I have found that by simply sitting down and discussing with a patient their fears and worries, the mutual uncertainty can be dramatically reduced. We were taught at medical school the importance of good communication skills and exploring a patient's idea, concerns and expectations. As junior doctors on the wards we are in one of the best positions to be able to do this, but I can't help but wonder how often we actually get the chance to do so.

Reading Iona Heath's article was a bit like eating a fruit cake: stuffed full with nuts and raisins of wisdom from Renaissance Humanists and other literary figures. So rich in fact as to be rather indigestible. Am I the only one wondering, however, if it all actually makes sense? For example, what does the statement “only because we do not understand everything and ....cannot control the future is it possible to live”: is it possible to live? Really ? Come on, pull the other one Iona!

But, rather than pull this article apart into its bits, I am curious to know what it really is about. I’m at pains to know if its all just a figment of erudite imagination: the irony is that her concluding lines exhort the reader to “consider the timely, the concrete, the local and the particular” when caring for the patient, but these are precisely the features missing from this article. There are no references to particular concrete instances of overdiagnosis and overmedicalisation which are be the basis for her argument about fear. Conversely, my morning’s surgery did not reveal any person coming in with “existential angst” as far as I could tell, but with real “fears” over, for example, bronchopneumonia (hospital admission), molluscum infection, eczema, a strange body rash I couldn’t quite diagnose, a gouty foot or possible tendonitis with thrombocytophilia, to name a few.

While reading excerpts of the giants of literature briefly gives me a heady feeling; I felt my feet were no longer on the ground, though my head was in the clouds of academia. That ground is the ‘concrete, timely and local’ of medicine, and this article did not help me to understand the overmedicalisation Iona is frightening me with, if this exists. Let alone help me to know whether fear does, in fact, drive such overdiagnosis and treatment.

Dear Editor,

Dr Iona Heath has explored some of the unnerving and fearful consequences of today’s medicine [1]. This article has indeed generated a lot of interest in all of us. Our congratulations to Dr Heath, and we do concur with Dr Heath’s essay. We are of the view that howsoever small, inconsequential, isolated, and statistically insignificant all this might be right now, exploitation of sickness must be stopped. We feel that such acts, as isolated and infrequent as they may be, do tend to erode the faith, goodwill, reputation, and the professional standing within the community.

Going a step further, we would also want to add that for the past several decades medicine has been straight-jacketed and nudged to conform to the “evidence based medicine”. Now isn’t it that all this “evidence” has been derived from whatever is already known, published, and is picked up on a specific search and is also found to be “statistically significant”. But then we also do know, don’t we, that there could be some other half baked and unfinished researches, start-ups, innovations, that might not have come to light and unheard of, but may carry or may have a view that just might be actually innovative and perhaps needed as well by the world. Yes, we have recently published a book that deals with 14 of our innovative medical techniques [2]. Our researches are incomplete, and as such were never designed or intended to be a ‘research’, but then they do give a reasonable direction for searching fresh evidence and possibly some meaningful non-surgical and painless techniques for such chronic morbidities like presbycusis, lumbar canal stenosis, migraine, sleep apnea, arthritis of knees, gynaecomastia, deviated nasal septum, ‘nose job’, face lift, benign prostatic hyperplasia, removal of excess flab and cellulite, and a possible modality for clot bursting in carotid or coronary circulation in dire emergency when no other help or better facilities or experts are available. In our case, all these innovations were accidental and were totally unplanned. For various reasons we were unable to take them to logical conclusions or to the extent of their coming up in any meaningful search, but we have gone on to speak our view that we hold for the future of medicine where rejuvenation and ‘overhauling’ to the extent possible can be done within a week. We may be totally wrong in our assumptions, but then we leave it to the world community to rehash and correct and complete from wherever we have stopped, in the absence of administrative and financial support, encouragement, etc. But then we are of the view that going by our innovations, possibly with the world community doing fresh and more research now, surgery may not be that essential for a number of conditions in the coming years [Figure 1]. Likewise we certainly do feel that there could just be much more worthwhile evidence available worldwide, but possibly just a little below the actual surface to be caught up in any meaningful search of “evidence” and may be in the form of poorly designed and unfinished researches by other doctors and scientists. All that needs to be done is to look beyond the tunnel and scrape below the surface as well to look for such incomplete but albeit a fresh approach.

The medical fraternity, scientific community, governmental agencies, non-governmental organizations, philanthropists, etc, should pool in their resources to have a deeper look at all such unfinished, unplanned, half-cooked researches that have been abandoned for whatever reasons, be it lack of administrative or financial support, or whatever, and try to start afresh in any such issue or area which might seem appealing or worthy to be pursued to the logical conclusions, and see if anyone of them is able to change or remodel the current “evidence” that is in vogue. Possibly this may usher in some new and fresh prospects which may help provide better prospects at management and just may prevent over-treatment as well.

Best regards.

References:

1. Iona Heath. Role of fear in overdiagnosis and overtreatment—an essay by Iona Heath.
BMJ 2014; 349: g6123

2. Chauhan R, Chauhan S, Parihar AKS. Innovative medical techniques showcased at international medical conferences. Lap Lambert Academic Publishing; 2014.

I strongly second Heath’s call for clinicians to be more tolerant of uncertainty, and agree with her that this requires courage, particularly given the prevalent culture of blame.

Nobody could disagree with the recommendation that people should be screened for their potential to benefit from risk-reducing interventions “only when medical care is appropriate and will produce more benefit than harm”; and most clinicians are well aware of the harms of swapping Sontag’s “good passport” for a provisional, “at risk” one (1-3). The snag with Heath’s recommendation is that defining and evaluating “benefit” and “harm”, and hence deciding when “medical care is appropriate”, requires more than just courage and certainly more than just statistical facts: it requires a complex weighing-up of preferences. Like her, I personally would prefer to avoid preventive medication. I am aware that this inevitably colours the way I talk with patients about screening, but I try to minimise this colouring because the conversation should centre on the patient’s preferences, not mine. Some well-informed people do choose screening; I am concerned that Heath’s strongly-expressed preference might well translate in practice into a new version of ‘doctor knows best’.

We need to acknowledge that helping each patient to make a decision which is right for them, in the way that they want to make it, is a complex and difficult task. Trying to help people not to fear death is a major additional challenge. As Heath says, doctors may well not be the best people to meet this challenge. In attempting to meet it, we should beware of actually increasing the very medicalisation Heath criticises, extending the remit of “healthcare” to encompass yet more aspects of human life.

1. Aronowitz R. The Converged Experience of Risk and Disease. Milbank Quarterly. 2009;Volume 87(2):335–542.
2. Frank AW. The Wounded Storyteller. Chicago: The University of Chicago Press; 1995.
3. Scott S, Prior L, Wood F, Gray J. Repositioning the patient: the implications of being 'at risk'. Social science & medicine. 2005;60(8):1869-79. Epub 2005/02/03.