Intended for healthcare professionals

Rapid response to:

Analysis Too Much Medicine

Mapping the drivers of overdiagnosis to potential solutions

BMJ 2017; 358 doi: (Published 16 August 2017) Cite this as: BMJ 2017;358:j3879

Rapid Response:

Overdiagnosis, as underuse, is malpractice: Calling a spade a spade is the prerequisite for improvement!

The Journal must be commended for its crusade against overdiagnosis: the first mention was in 1984.(1) The term has appeared in 217 articles including two recent ones: an analysis in the “too much medicine” section and an essay looking for solutions.(2,3) Sadly, this may be whistling in the wind.

First, the problem is not about “too much medicine” but simply about bad medicine.
Second, the term “malpractice” was never used once in these two articles.(2) To prescribe a risky procedure when there is no potential benefit is an error! This error has complex roots but the cornerstone is innumeracy.(4) Adding to it illiteracy is just flying in the face of the sad evidence to duck one's responsibilities.

Last, malpractice, as Janus, has two faces: Overuse and underuse. For the latter one example could be enough: only one-half of patients with cancer who smoke are counselled to quit although cessation is an important factor in the outcome (treatment effectiveness, overall survival, risk of second primary malignancies, quality of life).(5)

Could our system be more frequently the hall of shame than of fame than we believe? To hijack a quote from Séguéla, a French publicist, about his job: “Do not tell my mother that I am a healthcare professional, she believes me pianist in a brothel”.

1 Alm J, Hagenfeldt L, Larsson A, Lundberg K. Incidence of congenital hypothyroidism: retrospective study of neonatal laboratory screening versus clinical symptoms as indicators leading to diagnosis. BMJ 1984;289:1171-5.

2 Pathirana T, Clark C, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017; 358: j3879.

3 Carter SM. Overdiagnosis, ethics, and trolley problems: why factors other than outcomes matter—an essay by Stacy Carter. BMJ 2017; 358: j3872.

4 Braillon A. Discrepant expectations about benefits and harms: innumeracy plus illiteracy? JAMA Intern Med 2017;177:1225-1226.

5 Ramaswamy AT, Toll BA, Chagpar AB, Judson BL. Smoking, cessation, and cessation counseling in patients with cancer: A population-based analysis. Cancer 2016 15;122:1247-53.

Competing interests: No competing interests

23 August 2017
alain braillon
senior consultant
University Hospital. 80000 Amiens. France