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Analysis Essay

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

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6123 (Published 24 October 2014) Cite this as: BMJ 2014;349:g6123

Rapid Response:

As a general practitioner, involved in the care of dying patients and more broadly in the development of palliative care in primary care, I can but agree with Iona Heath’s analysis. Especially when she points out the fact that our society tends to « detaching notions of disease from the experience of suffering » [1]

When I work as a rural GP, in a practice surrounded by fields in Picardie, 90% of the patients I meet are doing quite well. Conversely, when I put the doctor's coat in the palliative care mobile team of our local hospital, 99% of the patients I see are living with severe (multiple) conditions. Navigating between these different care settings matters a lot to me. This allows me to better understand what the patients have left on the side of the road as they progressed on their own illness trajectory — and what implications this journey had on their health.

General practitioners encounter patients in a context located halfway between the scientifically overdetermined world of biomedicine, and the unpolarized environment of daily life. The experience of illness (and more specifically of chronic illness) causes a disruption, both biological and biographical, in patients' life [2]. There is a 'before' and an 'after' the onset of the illness. We have a responsibility, as health care professionals, in doing a mediation between the biomedical terminology that reigns in the 'kingdom of disease' and the patients’ everyday vernacular.

Over-emphasizing on biomedical language and considerations equates to seeing the patient as an aggregate of molecules or a bearer of risk factors, and not as a person living among us, in our world. It is the first step towards overdiagnosis. Such a process might have been the consequence, at a certain era, of a certain type of acculturation (through 'detachment'), at stake when medical students had to learn how to cope with medical uncertainty [3]. Are we sure that it is not still the case today?

Besides structural, environmental or socio-economic determinants, population health is partly the result of actions by multiple dyads composed of a patient and a health professional (or a group of professionals). This has two implications on health outcomes: 1/ they depend on the quality of the health partnership established between a patient and a health professional; 2/ each patient, not only professionals, has a direct impact on population health.

So we have to listen to what they have to tell us. In their own words (or any other way of expression). If we show enough curiosity about the content of their experience, maybe we will be able to build a genuine and strong partnership. We need this partnership, because as Heath says, "it is only within relationships of trust that fear can be in any way contained" [1]. Uncertainty is a solid common ground to build such a partnership on, because it is experienced both by doctors (cognitively) and patients (emotionally). This could be a good opportunity to give up 'detached concern' for real empathy [4].

In my field of practice (primary palliative care), health promotion does not mean fighting against or monitoring risk factors — which would be even more absurd at the end of life. I keep in mind this sentence by Herman Broch, from his magnificent novel The Death of Virgil [5]:

Oh mortal is that chance which is not contained in ourselves and in which we are not contained; all that we comprehend of it is death, for death reveals itself to us in the phenomenon of chance, verily only in chance, but we, neither containing ourselves nor contained in ourselves, bearing death within us, are only accompanied by it, it stands at our side, as it were by chance.

Health promotion at the end of life means giving to dying patients the opportunity to laugh, to love, to connect with others, to celebrate. Even with death at their side.

References:

[1]. I. Heath. Role of fear in overdiagnosis and overtreatment. BMJ 2014; 349: g6123
[2]. K. Charmaz. Experiencing chronic illness. In G. Albrecht, R. Fitzpatrick & S. Scrimshaw (ed.), The handbook of social studies in health and medicine. 2000. London: Sage
[3]. H. Leif and R.C. Fox. Training for 'Detached Concern' in Medical Students. In H. Leif et al. The Psychological Basis of Medical Practice. New York: Harper and Row.
[4]. J. Halpern. From detached concern to empathy. Humanizing medical practice. 2001. New York: Oxford University Press
[5]. H. Broch. The Death of Virgil. 1945. (JS Untermeyer, tr.). New York: Pantheon

Competing interests: No competing interests

30 November 2014
Sébastien MOINE
General Practitioner, PhD student
Laboratoire Educations et Pratiques de la Santé, EA 3412, Université Paris 13
Multiprofessional Primary Health Care Center "The Vines of the Abbey", 60130 Saint Just en Chaussée, France