I congratulate Dr Hofmann on this incisive and entertaining essay. It elucidates much which is true, but that still requires emphasis. I am a bit more optimisitic that our profession does harbour plenty of sceptics, and that we will be able to sieve important advances in due course. The cutting-edge will necessarily be led by fanatics.
I recognise, and am daily frustrated by, the 'Self perpetuating loop of development in diagnostic technology' described in Figure 1, but I also think it oversimplified. Advances in diagnostic technology do not occur in isolation, but rather in a context of changing populations and improving treatments.
One of the diseases you use for illustration is Pulmonary Embolism (PE), citing the over-diagnosis of small PE described by Wiener et al. in this journal (1). We have just published data from Edinburgh which shows that over the last decade, with increasing investigation rates we diagnosed many more PEs per year, but saw no increase in the proportion of small emboli. The spectrum of PE severity has remained remarkably constant (2).
Either these PEs always existed and we didn’t know about them (a sub-clinical iceberg), or the prevalence of severe PE is genuinely increasing, perhaps related to the prevalence of multimorbidity (3).
Whilst I sympathise, every working hour, with the desire to see a more reflective and responsible implementation of health technology, I bear no hope that it will ever happen. Patients and professionals will want to have available technology. Who will stand in their way? We just need doctors with the wit and experience to understand what’s happening, and time to reflect and communicate what should happen next time. This is no easier, but your article helps.
1. Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ. 2013;347:f3368.
2. Morley NC, Muir KC, Mirsadraee S, van Beek EJ, Murchison JT. Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg? Clin Radiol. http://dx.doi.org/10.1016/j.crad.2015.07.010
3. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380:37-43.
Rapid Response:
Re: Too much technology and Too many PEs
I congratulate Dr Hofmann on this incisive and entertaining essay. It elucidates much which is true, but that still requires emphasis. I am a bit more optimisitic that our profession does harbour plenty of sceptics, and that we will be able to sieve important advances in due course. The cutting-edge will necessarily be led by fanatics.
I recognise, and am daily frustrated by, the 'Self perpetuating loop of development in diagnostic technology' described in Figure 1, but I also think it oversimplified. Advances in diagnostic technology do not occur in isolation, but rather in a context of changing populations and improving treatments.
One of the diseases you use for illustration is Pulmonary Embolism (PE), citing the over-diagnosis of small PE described by Wiener et al. in this journal (1). We have just published data from Edinburgh which shows that over the last decade, with increasing investigation rates we diagnosed many more PEs per year, but saw no increase in the proportion of small emboli. The spectrum of PE severity has remained remarkably constant (2).
Either these PEs always existed and we didn’t know about them (a sub-clinical iceberg), or the prevalence of severe PE is genuinely increasing, perhaps related to the prevalence of multimorbidity (3).
Whilst I sympathise, every working hour, with the desire to see a more reflective and responsible implementation of health technology, I bear no hope that it will ever happen. Patients and professionals will want to have available technology. Who will stand in their way? We just need doctors with the wit and experience to understand what’s happening, and time to reflect and communicate what should happen next time. This is no easier, but your article helps.
1. Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ. 2013;347:f3368.
2. Morley NC, Muir KC, Mirsadraee S, van Beek EJ, Murchison JT. Ten years of imaging for pulmonary embolism: too many scans or the tip of an iceberg? Clin Radiol. http://dx.doi.org/10.1016/j.crad.2015.07.010
3. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380:37-43.
Competing interests: No competing interests