I HAVE been thinking and writing about overdiagnosis for some time, and sometimes thoughts and information can come together to make things clearer.
It’s good to see the Choosing Wisely campaign has come to Australia — it’s a positive development. However, in my view, it’s not ambitious enough.
Another stir of interest came along last month with the Four Corners report called “Wasted”.
The program discussed the lack of evidence surrounding a number of diagnostic tests and surgical procedures that continue to be done, and the links to the Medicare Benefits Schedule. The role of GPs in referring patients into diagnostic or treatment “journeys” was presented.
What the program didn’t include was a cogent discussion of the motivating factors behind overdiagnosis.
Most of us who order tests and referrals know intuitively what motivates us. If we’re honest, it’s often fear.
We may not feel scared but, deep down, we know that we can be crucified for “missing something”. It’s bad enough to be called out by a colleague over an error, or complained about by a patient — or even sued — but that’s not entirely it.
We are fearful that we might actually harm someone.
For all the accusations against doctors of corruption or greed, we care about our patients and the idea that we might miss an important diagnosis, and cause that person harm, is terrifying.
Fear is a strong motivator — stronger than insight or knowledge. That’s why education just isn’t enough.
Even though we might know what the guidelines say, or what the evidence shows, just one anecdote about an unpredictable event that went horribly wrong can have us retreat to primal emotion. Unless we understand and acknowledge these dynamics, we won’t be able to change them.
Much of the discomfort with the Four Corners program focused on two areas. First, the evidence surrounding effectiveness in subgroups of patients, and second, the role of the GP (and, I would add, emergency department doctor) as referral agent.
The way I see it, good medicine relates to basic skills: knowing your pathophysiology and being able to communicate with your patient. If we don’t trust our own clinical skills, and keep referring for tests or consultations with other doctors, then we teach our patients not to trust us.
We teach them to want a test, or to see a specialist, “just to make sure”.
The problem is, sending patients off for a test or another consultation usually doesn’t help to make us sure. Sending a low-risk patient for a test increases the risk of false-positive results and the harms that that can cause. Sending a patient with a benign condition to another specialist sends the message that we are worried that there might be something serious going on.
These fears transmit to the patient and can influence the subsequent testing and treatment offered by the consulting doctor.
If we, as referring doctors, inappropriately send a patient on a journey of investigation or treatment that results in inappropriate action, then we are complicit in that action.
What to do, then?
We need to be honest and kind to ourselves and each other, and to our patients. We have to accept that, although clinical judgement isn’t perfect, tests and procedures aren’t perfect either.
We also have to own all of our complications — not just the harms of “missing something”, but also the harms of “doing too much”.
Most of all, we need to make clear to our patients that, in doing less, we are caring for them more.
Choosing to do less isn’t always withholding something good from patients. Sometimes, it’s saving them from something bad.
We live in a great country, and we have some of the best health outcomes in the world. Let’s not be afraid.
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.