Re: Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine
Dear Sir,
People receiving unnecessary treatments: accurate diagnosis is key.
Our experience managing people with low back pain supports Malhotra’s view that people receive unnecessary treatments (1). We agree with Malhotra that diagnosis drives treatment. However, we suggest that emphasis needs to be placed on achieving accurate diagnosis rather than identifying, “over-diagnosis”.
Simple logic underpins medical practice. Clinicians are required to make diagnoses. Explicit diagnoses underpin meaningful discussions about management options, their mechanisms of action and their potential risks and benefits. The more certain the diagnosis, the more certain the outcome of a particular intervention.
Consider lumbar nerve root compression (LNRC). Our experience is that LNRC is underdiagnosed, and people with this potentially surgically manageable condition are subjected to a range of unnecessary treatments that are, in this context, of limited value (2). The likely source of LNRC misdiagnosis is two-fold. There is a major discrepancy between the symptoms specialists recognise as potentially attributable to LNRC, and the guidance available to non-specialists (3). At the same time, “non-specific low back pain” (NSLBP), is often managed as a diagnosis when it is in fact a common symptom which will almost certainly have a multitude of potential causes, one of which may be LNRC.
Hookway and colleagues’ article (4) highlighted for us similarities between irritable bowel syndrome (IBS) and non-specific low back pain (NSLBP). Both IBS and NSLBP are very common, have pain as the principle symptom, and are managed largely in primary care. More importantly, both IBS and NSLBP are managed as formal diagnoses supported by NICE guidelines when, in fact, it is more accurate to describe the terms IBS and NSLBP as labels for collections of symptoms which are themselves the final common pathway of a diverse range of origins (5).
The key messages of our own editorial on the problems of definition and diagnosis in back pain apply to IBS and possibly to other areas of medicine (for example, bipolar disorder). We provide evidence to suggest that the current approach to managing low back pain is illogical and the guidelines are not helpful for these complex symptoms (6).
We suggest the way forward may be aided by committees but it is probably more important to:-
• Make sure clinicians have enough time with patients to take an appropriate history.
• Make sure clinicians have sufficient time to keep up to date with available evidence & to engage with clinical research.
• Invest in research measuring the risks and benefits of intervention.
Yours Faithfully,
Tim Germon, Consultant Spine Surgeon
Jeremy Hobart, Professor of Neurology & Clinical Measurement
References
1. Malhotra A. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ 2015;350:h2308 doi: 10.1136/bmj.h2308.
2. AC Dias, DS Jeyaretna, JC Hobart, TJ Germon Treating pain resulting from nerve root compression: a ride on the not so magic roundabout. Journal of Bone & Joint Surgery, British Volume 94 (SUPP X), 061-061.
3. Germon, Tim, William Singleton, and Jeremy Hobart. "Is NICE guidance for identifying lumbar nerve root compression misguided?." European Spine Journal 23.1 (2014): 20-24.
4. Hookway, Cheryl, et al. "Irritable bowel syndrome in adults in primary care: summary of updated NICE guidance." BMJ 350 (2015): h701.
5. Germon Tim, Hobart Jeremy. http://www.bmj.com/content/350/bmj.h701/rr
6. Germon, Timothy J, Hobart, Jeremy C. Definitions, diagnosis, and decompression in spinal surgery: problems and solution. The Spine Journal 2015;15(3):S5 - S8.
Competing interests:
No competing interests
21 May 2015
Tim Germon
Spine Surgeon
Prof Jeremy Hobart
Derriford Hospital & Plymouth University Peninsula Schools of Medicine & Denistry
Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, PL6 8DH
Rapid Response:
Re: Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine
Dear Sir,
People receiving unnecessary treatments: accurate diagnosis is key.
Our experience managing people with low back pain supports Malhotra’s view that people receive unnecessary treatments (1). We agree with Malhotra that diagnosis drives treatment. However, we suggest that emphasis needs to be placed on achieving accurate diagnosis rather than identifying, “over-diagnosis”.
Simple logic underpins medical practice. Clinicians are required to make diagnoses. Explicit diagnoses underpin meaningful discussions about management options, their mechanisms of action and their potential risks and benefits. The more certain the diagnosis, the more certain the outcome of a particular intervention.
Consider lumbar nerve root compression (LNRC). Our experience is that LNRC is underdiagnosed, and people with this potentially surgically manageable condition are subjected to a range of unnecessary treatments that are, in this context, of limited value (2). The likely source of LNRC misdiagnosis is two-fold. There is a major discrepancy between the symptoms specialists recognise as potentially attributable to LNRC, and the guidance available to non-specialists (3). At the same time, “non-specific low back pain” (NSLBP), is often managed as a diagnosis when it is in fact a common symptom which will almost certainly have a multitude of potential causes, one of which may be LNRC.
Hookway and colleagues’ article (4) highlighted for us similarities between irritable bowel syndrome (IBS) and non-specific low back pain (NSLBP). Both IBS and NSLBP are very common, have pain as the principle symptom, and are managed largely in primary care. More importantly, both IBS and NSLBP are managed as formal diagnoses supported by NICE guidelines when, in fact, it is more accurate to describe the terms IBS and NSLBP as labels for collections of symptoms which are themselves the final common pathway of a diverse range of origins (5).
The key messages of our own editorial on the problems of definition and diagnosis in back pain apply to IBS and possibly to other areas of medicine (for example, bipolar disorder). We provide evidence to suggest that the current approach to managing low back pain is illogical and the guidelines are not helpful for these complex symptoms (6).
We suggest the way forward may be aided by committees but it is probably more important to:-
• Make sure clinicians have enough time with patients to take an appropriate history.
• Make sure clinicians have sufficient time to keep up to date with available evidence & to engage with clinical research.
• Invest in research measuring the risks and benefits of intervention.
Yours Faithfully,
Tim Germon, Consultant Spine Surgeon
Jeremy Hobart, Professor of Neurology & Clinical Measurement
References
1. Malhotra A. Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine. BMJ 2015;350:h2308 doi: 10.1136/bmj.h2308.
2. AC Dias, DS Jeyaretna, JC Hobart, TJ Germon Treating pain resulting from nerve root compression: a ride on the not so magic roundabout. Journal of Bone & Joint Surgery, British Volume 94 (SUPP X), 061-061.
3. Germon, Tim, William Singleton, and Jeremy Hobart. "Is NICE guidance for identifying lumbar nerve root compression misguided?." European Spine Journal 23.1 (2014): 20-24.
4. Hookway, Cheryl, et al. "Irritable bowel syndrome in adults in primary care: summary of updated NICE guidance." BMJ 350 (2015): h701.
5. Germon Tim, Hobart Jeremy. http://www.bmj.com/content/350/bmj.h701/rr
6. Germon, Timothy J, Hobart, Jeremy C. Definitions, diagnosis, and decompression in spinal surgery: problems and solution. The Spine Journal 2015;15(3):S5 - S8.
Competing interests: No competing interests