Intended for healthcare professionals

Rapid response to:

Analysis Essay

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

BMJ 2014; 349 doi: (Published 24 October 2014) Cite this as: BMJ 2014;349:g6123

Rapid Response:

“Defensive medicine”, including over-diagnosis and over-investigation, entails a retreat from our obligation to make good clinical judgement. Too many doctors fail to understand that attempting single-mindedly to avoid all risk fails our patients and causes net harm. An essential component of our job is to manage risk.

I believe the contemporary tsunami of over-investigation can be solved by discouraging currently ubiquitous terms such as “differential diagnosis” and “rule-out”. Instead of listing every apparently conceivable diagnosis, doctors should be trained to become confident in stating singularly what they think is going on. To achieve this level of clinical gestalt requires mostly only two things – to take a history, and to think. Cross-examining the patient to really understand what their story is in a vivid narrative sense, enables a reorientation from guessing “what else could be going on” to confidently saying what “it could not be”.

And in those rare cases where that rare “something else” is going on, again the clue is invariably in the history!

Competing interests: No competing interests

09 November 2014
Bernard Freudenthal
Specialty Registrar (ST3) in Endocrinology & Diabetes
Watford General Hospital
Vicarage Road, Watford, Herts, WD18 0HB