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:

Re: Mapping the drivers of overdiagnosis to potential solutions

As a GP concerned to limit the growth of medicalisation and ‘healthism’(1), I welcome Pathirana et al’s account of some of the ways this might be achieved. But I take issue with two points in their opening paragraph. First, while ‘a growing body of evidence’ indicates that diagnosis and treatment can both cause harm, no amount of evidence can tell us how much is ‘too much’ medicine  this is a value judgement. Second, any intervention offered to a person who feels well at present relates to a health problem that may ‘never cause them harm’. Screening tests particularly often involve ‘“the detection of abnormalities that are not destined to ever bother” most of us. Implying that any individual can be ‘overdiagnosed’ makes no sense without a crystal ball. In the thyroid cancer example presented, what we need to know is how many lives were lengthened for every 100,000 people diagnosed and treated. Once available, this information will inform a value judgement about the number of people who should suffer diagnosis and treatment in return for one life lengthened. This value judgement can be made by health economists who calculate which interventions are cost effective, or by individuals who evaluate the pros and cons of an intervention they are offered. The challenge for clinicians is to help people do this evaluating in the consulting room.
While accepting Pathirana et al’s recommendation that campaigns should challenge the public’s current beliefs about how much medicine is just right, I should like the overdiagnosis conversation to accept that it is not doctors’ job to specify this ‘right’ amount. Also, the assumption that the public believe ‘more is better’ is open to challenge. My own research (2) suggests that in accounting for their everyday decisions about preventive medication, patients negotiate the tension between ‘medical progress’ and ‘medicalisation’. I see less evidence that the biomedical community has yet engaged with this tension, but am encouraged that a forthcoming RCGP meeting focuses on both over- and under-treatment. Such engagement is urgently needed as genetic screening begins to generate an enormous number of new ‘at risk’ labels, a juggernaut that needs to be guided by people who simultaneously fear medicalisation and welcome medical progress.

1. Crawford R. Healthism and the medicalization of everyday life. International Journal of Health Services. 1980;10(3):365-8.
2. Polak L. What is wrong with ‘being a pill-taker’? The special case of statins. Sociology of Health and Illness. 2017;39(4):599–613.

Competing interests: No competing interests

24 September 2017
Louisa Polak
GP and PhD student
London School of Hygiene and Tropical Medicine