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A GROWING international backlash against overtreatment is gathering pace, with a movement led by prominent doctors seeking to mobilise the medical community to stop possible harms to patients.
A feature article in the BMJ reports that the movement is challenging the assumption that more health care is better. (1)
Although the issue had been bubbling in the background for decades, technological advances in medicine had forced it onto the mainstream medical agenda, according to Australian evidence-based medicine expert, Professor Paul Glasziou, from Bond University.
Professor Glasziou is on the steering committee for next year’s Preventing Overdiagnosis conference, which will be hosted by Dartmouth Institute for Health Policy and Clinical Practice in the US in partnership with Queensland’s Bond University, the BMJ, and New York-based consumer organisation Consumer Reports.
“This is not sudden, it has been building momentum over time, but better diagnostic tools have been a key trigger”, Professor Glasziou said.
“Overdiagnosis wasn’t a problem 100 years ago as we didn’t have the technology to do that”, he said. Changing definitions of disease were also leading to overdiagnosis that resulted in unnecessary procedures, treatments and worry.
“There has been this gradual increase over time and we’ve reached a critical point as we can now classify everybody as having some sort of illness”, he said.
Preventing Overdiagnosis would be a scientific conference bringing together doctors thinking about different parts of the problem, with the aim of building a better awareness of the broader issues.
“We want to understand the problem better so we can work out how to turn this ship around”, Professor Glasziou said.
“If we can rein it in, we will have more resources to treat those people who need it and stop harming those who don’t”, he said.
The BMJ article reported on the Avoiding Avoidable Care conference held in April this year, described as the first conference held in the US to focus exclusively on overtreatment.
The article said the conference attracted a “who’s who of American medicine”, who provided examples of unnecessary care in many areas of medicine including the use of screening tests, surgery and imaging technology, and at the end of life.
Speakers also identified multiple causes of overtreatment, including malpractice fears, supply-driven demand, knowledge gaps, biased research, profit seeking, patient demand and financial conflicts of clinical practice guideline writers.
One speaker said that medical students “were taught to do things, not how to know what not to do”, the article said
There was general agreement on some solutions to the problem, such as using experts free of conflicts of interest to write guidelines, implementing shared decision making, reducing excess hospital capacity, and reforming tort law.
– Amanda Bryan
Posted 8 October 2012
There are several scenarios. Over-treatment and over-dagnosis because of lack of experience, vested interest e.g. to fill beds in psychiatric care facility, payment for service not for duty of care, and failure to tell the patient in clear, plain and simple language what they don’t wish to hear – as is the case with most people – e.g. psychiatric care/Boards/interfering relatives and unaccountable Officers of government e.g. public advocate/Tribunals, fear of litigation, inappropriate Board bullying and policy e.g. mandatory reporting and lack of education e.g see P Steele above, and absence of good see Egg comment above and failure to refer to have specialist assessment and experienced directive of care.
I suspect that a lot of the dietary “sensitivity” diagnoses come not from mainstream medical practitioners but from a range of non-science-based therapists. Our community seeks simplistic answers to complex questions. Providers who speak with confidence and offer a simple solution are becoming more and more popular, especially if they preach “empowerment”. It is a false sense of empowerment, that encourages a “label” and a solution for a set of symptoms, as well as dependence of the therapist. Orthodox practitioners are then found wanting if they don’t offer a label and a remedy. Perhaps this leads orthodox practitioners to do more testing in order to be able to “label” a set of symptoms.
The fasionable diagnosis of gluten and dairy “sensitivity” as a cause of almost anything in kids who have whatever problem, causes great anxiety for the parents, cures nothing and puts fear to even try taking the kids off this “diet”. And when do they attempt normal food?
These “expert” doctors who charge high fees for their “expert” advice should be taken to task
I think that the problem is not so much overdiagnosis as narrowly defined or poorly addressed diagnoses.
For example, we diagnose metabolic syndrome which has components such as hypertension and hypertriglyceridaemia and associated conditions like gout, and type II diabetes, but we fail to effectively address the primary problem which is abdominal obesity.
This in turn is a symptom of poor dietary and exercise patterns, as are many other conditions, like ischaemic heart disease and (according to the WHO) several common cancers. However, in general, poor dietary and exercise patterns are not what gets diagnosed and treated, merely their results.
Plenty of comments on the financial costs, but we shouldn’t forget the harms to our patients. An easy example (importantly in a specialty other than mine!) is the use of stents in stable coronary artery disease, despite the evidence and guidelines suggesting people have better quality of life and less followup procedures if stable CAD is managed with medication alone.
http://health.newamerica.net/blogposts/2011/less_is_more-55062
http://archinte.jamanetwork.com/article.aspx?articleid=769857
I agree with a lot of the above. Perhaps the problem could be addressed with training , e g., in history and examination first, prior to investigation and treatment, so junior ED doctors do not order a chest xray before examining the chest , nor order a CT prior to consulting a more senior doctor, use of Therapeutic Guidelines, prior to treatment, and PBS restrictions for statin treatment , such as prior treatment by a Dietician and ongoing Dietician review.
The problem is different in remote and rural areas, where diagnosis and treatment may be empirical due to lack of doctors, nurses, allied health etc.
As long as we’re getting it right, not missing things and not ignoring underlying factors, we can afford to be confident that we are not over diagnosing:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861517/
The ‘yes’ and the ‘no’ components once again—-somewhat like refusing antibiotics for respiratory tract infections, which are eventually given when a person is in dire straights with pneumonia or acute bronchitis!
or giving prescription medicines for ‘anxiety and depression’ whilst ignoring the causes e.g.financial difficulty due to over-commitment and impending unemployment,and such other life situations.
This has been a recognised problem since a medical workforce survey in the 90s which found the medical workforce was in excess which was leading to overdiagnosis and treatment of people in affluent areas and relative under supply and under treatment in poorer or remote areas. Subsequent reports have claimed workforce oversupply. The resulting increase in doctors both through overseas recruitment and increase in local trainees will only make the problem worse.
If GPs had strict guidelines for medicare rebates on all imaging and pathology tests then far fewer would be ordered and doctors fear of litigation would be much diminished.
eg CT of lumbar spine only if pain is of acute onset or after physiotherapy assessment.
Easier said than done. A lot of it is driven by patient demands for tests, and worries about litigation for missing a diagnosis. Those issues need to be addressed rather than just critising doctors who are genuinely trying their best not to miss things.
I agree – the most potent example in this country is treatment with statins particularly beyond the age of 80 & continued prescribing in dementia patients. The recent call by a UK professor that everyone over 50 should be on statins is an example of health care lunancy
Will be exacerbated by the current growth in medical trainee placements
“Over treatment” is becoming a very big financial issue as well as a medical problem. Economic austerity has become the order of the day and as doctors we have to rein in on all unecessary investigations and treatment.