Focusing on overdiagnosis as a driver of too much medicine
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3494 (Published 17 August 2018) Cite this as: BMJ 2018;362:k3494All rapid responses
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Those currently voicing concerns about overdiagnosis will be interested to learn that discerning doctors raised similar concerns more than half a century ago. In 1967 Dr John Stallworthy, Professor of Obstetrics and Gynaecology at Oxford, praised a new book by Australian doctors Malcolm Coppleson and Bevan Reid as ‘remarkable’ and ‘a great achievement by two young scholars’.
In their book on ‘preclinical carcinoma of the cervix uteri’, Coppleson and Reid wrote, ‘We believe the ease of diagnostic methods and the vigour and skill of those employing them have presently outstripped the availability of basic knowledge or their assimilation and correct interpretation.’ They considered there was much ‘room for doubt of many of the more serious interpretations placed on cells or tissues removed from the cervix’ by cone biopsy, and explained, ‘These thoughts have become the basis of our conservative approach’.
These viewpoints were closely echoed in Professor Brodersen and colleagues’ comment in this contribution to the BMJ, where they wrote: ‘Our ability to diagnose often outpaces our understanding of prognosis, making some degree of overdiagnosis inevitable…. Technological advances… aggravate the problem, helping us find less severe abnormalities earlier, long before we know what they mean or whether they need to be treated.’
Stallworthy considered Coppleson and Reid’s approach ‘opportune and challenging at a time when community-screening programmes are not only identifying increasing numbers of women with “doubtful” cervices, but are submitting many of them to the danger of unnecessary mutilating surgery’. However, these views were then, and are still now, often silenced by what Brodersen et al. call the ‘popularity paradox’.
Reference: Malcolm Coppleson and Bevan Reid, with the assistance of Ellis Pixley, Preclinical Carcinoma of the Cervix Uteri: Its Nature, Origin and Management, Oxford: Pergamon Press, 1967.
Linda Bryder DPhil (Oxon) FRSNZ
l.bryder@auckland.ac.nz
Competing interests: No competing interests
The driver of overdiagosis is the fear of missing something driven by fear of over regulation and the increasing medico-legal climate we live in.
We have come to an impasse: it's for society to decide if we should tolerate low risk medical practice or zero risk medical practice. Zero risks calls for over investigating, over referring, etc, with all its attendant costs
The politicians talk of "never events"; how can there ever be never events,? Yes, we can reduce substantially the risk of these occurring but not to zero, so by putting the bar so high for us to jump, we take away the message of zero risk as practitioners.
Let us practise like clinicians not quasi clinicians, otherwise we all pay the price.
Competing interests: No competing interests
As a busy GP in urgent care, I feel the need to point out the impression I get of almost an exponential rise in acute symptoms which have no physical or psychological explanation. Over 90% of acute chest pain I see is probably undiagnosable. Similar for abdominal pain. Dramatic acute presentations which in my younger days would have had a high likelihood of revealing a significant problem are now followed up and the eventual diagnosis is nothing or a spurious, specious conclusion.
This is important because the most likely diagnosis is "nothing" but that is rarely discussed with the patients. Spurious and specious serious issues are used by younger doctors and many others to hang their own and the patient's hat on and this drives excess investigation. Time is the main treatment but that is now increasingly denied to us and seen as too casual. If you have a symptom which is probably nothing in 100 individuals and wait 1 week and only 5 are left with the symptom, you investigate 5. If you investigate all 100 you have done 95 investigation which were not required, Increasingly all 100 are getting investigation,
And the final question is, "How do you teach, "it's probably nothing"".
Competing interests: No competing interests
Re: Focusing on overdiagnosis as a driver of too much medicine
A stone thrown and a word spoken
Overdiagnosis can also occur when age related changes are given a medical diagnosis. In the last two decades MRI scans for neck and back pain have also been caught up in the Popularity paradox with the demand for MRI scans on an exponential increase (Ref 1). This is in spite of the evidence which suggests that the knowledge of imaging findings is associated with a lesser sense of well-being (Ref 2).
Everyone ages. So do their internal structures. The external effects of aging like wrinkles, sagging, greying, balding are normal. There are usually not taken into account in routine clinical consultations. When a patient visits for a consultation we do not remark that they are wrinkled or bald. However, it seems acceptable to look at a MRI scan of the spine with natural age related changes and term it as “degenerative disc disease (DDD)”.
A 40 year old is unlikely to possess the smooth skin of a baby. Equally the 40 year old is unlikely to have a pristine spine. It is likely that a 40 year old will demonstrate age related changes. In some, the changes are more pronounced and in some the changes are less obvious. The age related changes on the spine like disc degeneration is usually also, not the cause of the patient’s symptoms1.
However, the identification of age related changes on the MRI scan of the spine sometimes becomes the escape path in many medical consultations. It seems the presence of the age related changes justifies the need for the consultation. In addition, some health professionals may use adjectives like “worn out”, “crumbling” or “knackered” to enhance the effects of their find.
It is easy for a doctor to use terms that depict the condition in an unfavourable light. Using such language can leave an imprint in a patient’s mind and cause fear avoidance (Ref 3), i.e. afraid of moving and using their spine. This can in fact endorse inactivity, which is detrimental. Engaging in physical activity and back exercises is the main treatment for back pain. Using negative language can make it seem as though they are not able to move or carry on with their daily lives. This can have an adverse effect and increase disability.
The size of surrounding spinal muscles (bulk) and the fat infiltration is also apparent on MRI scans (Ref 4). It is important that consultations focus on this rather than on the natural degeneration. Exercising and improving the strength of these core muscles is the only modifiable factor in mechanical back and neck pain. In essence, doctors and other healthcare professionals should be cautious and positive in consultations with patients. Words once spoken cannot be retrieved, just as stones once thrown. Focusing on the weak muscles provides hope and empowers the patient to self manage their pain by exercising and strengthening the para-spinal muscles (Ref 5).
References
1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001 Feb 1;344(5):363-70.
2. Modic MT, Obuchowski NA, Ross JS, Brant-Zawadzki MN, Grooff PN, Mazanec DJ, Benzel EC. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005 Nov;237(2):597-604.
3. Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014 May 1;14(5):816-36.e4.
4. Teichtahl AJ, Urquhart DM, Wang Y, Wluka AE, Wijethilake P, O'Sullivan R, Cicuttini FM. Fat infiltration of paraspinal muscles is associated with low back pain, disability, and structural abnormalities in community-based adults. Spine J. 2015 Jul 1;15(7):1593-601
5. Kliziene I, Sipaviciene S, Klizas S, Imbrasiene D. Effects of core stability exercises on multifidus muscles in healthy women and women with chronic low-back pain. J Back Musculoskelet Rehabil. 2015;28(4):841-7.
Competing interests: No competing interests