Issue 25 / 8 July 2013

IN recent weeks the world’s leading medical journals have published articles about the overtreatment of mild hypertension, the risks of breast cancer overdiagnosis, and the lack of effectiveness and potential harms of general health checks.

As the studies of dangerous excess mount, so too does the effort to raise awareness about the problem. JAMA Internal Medicine now has a regular “Less is more” feature, the BMJ has just launched its “Too much medicine”  campaign, and professional societies in the US are running the “Choosing wisely” initiative, highlighting overused tests and treatments.

In the field of mental health few could have missed the global fight over the DSM–5 and vociferous claims it will further fuel the medicalisation of normal life.

There’s little doubt that the market-based system in the US is the epicentre of excess — where health care now comprises almost one-fifth of the entire economy — but the problem affects many nations.

With breast cancer for example, estimates based on incidence studies suggest one-third of invasive cancers diagnosed by screening mammography in NSW may be overdiagnosed — in other words, the cancer would not have gone on to harm the woman.

The probable causes of overdiagnosis and overtreatment are complex — technological change, commercial gain, professional imperialism, fears of litigation, perverse incentives and our deep cultural faith in early detection. But despite the complexity and enormity of the challenge, it’s surely time to try to work out how we can wind back the harms of too much medicine.  

A group of Australian researchers are a key driving force behind the first international scientific conference on overdiagnosis to be held in the US this September. The Dartmouth Institute for Health Policy and Clinical Practice is a logical host for the Preventing Overdiagnosis conference, with its proud history of medical scepticism and impeccable credentials on the dangers of too much medicine.

Resulting from a small meeting on Queensland’s Gold Coast last year, the conference is being run in partnership with the BMJ and one of the world’s most influential consumer organisations, Consumer Reports. It will feature 90 scientific presentations on the problem and its solutions, and keynote speakers include Dr Virginia Moyer, the chair of the US Preventive Services Task Force, Dr Allen Frances, chair of the DSM IV, and Dr Barry Kramer, a senior director at the National Cancer Institute, which has made overdiagnosis one of its research priorities.

Along with the research and the conferences, the time is ripe for a lot more discussion about what can be done in the clinic and the classroom, how we can communicate the counterintuitive message that less is sometimes more, and how we can develop and evaluate effective policy responses.

The aim, after all, is not just more meetings and peer-reviewed papers, but fewer healthy infants labelled unnecessarily with gastro-oesophageal reflux disease, less distress overdiagnosed as mental illness, and fewer of our elders assailed by out-of-control polypharmacy. The less we waste on unnecessary care, the more resources there are for those in genuine need.

Along with innovations in genetics and information technology, one of the exciting areas in medicine in the 21st century will be how to wind back unnecessary excess — safely and fairly.

 

Ray Moynihan is a senior research fellow and PhD student at Bond University, and co-organiser of the Preventing Overdiagnosis conference being held at Dartmouth, US, 10–12 September 2013. www.preventingoverdiagnosis.net

Jane McCredie is on leave.
 

5 thoughts on “Ray Moynihan: Preventing excess

  1. Dr Judith O'Malley-Ford says:

    the concept of overdiagnosis, and overtreatment is already here, alive and well in Australia. It is applauded by breast cancer surgeons, urologists re treatment of prostate cancer, and treatment of some renal cancers. Until such time as medical science can map the human genome, and prove that some cancers do not need treatment, the hypothesis of  overtreating these cancers, must remain a hypothesis only. It may well  be true, but we dont have enough information at present to fully test this theory.

  2. Romi Goldschlager says:

    Overdiagnosis and medicalisation is a discussion well worth having. Why do we medicalise everything? How much does the fear of litigation cause us to throw reason to the wind?

  3. Dr George Margelis says:

    Very interesting article Ray.

    One of the possible uses of information technology in healtthcare is to ensure treatments are optimised for individuals, based on good evidence. To do this we need to provide high quality decision support tools to clinicians AND patients so that they both understand the pros and cons of diagnoses and the associated management. A key is how we demonstrate probabilities to patients, an area that still needs a lot of research.

    One challenge we are facing is the rise of “Dr Google” and the use of overly simplistic self diagnosis and management tools which generally over suggest diagnoses, recommend new and expensive treatments, or even worse recommend evidence free treatments. As many of these tools are funded by advertising there is a potential  incentive to do so. Without a proper clinical governance around such systems we may well find that overdiagnosis driven by advertisiong revenue may become our biggest challenge.

    To quote Kenny Rogers “Know when to hold them, know when to fold them” applies to clinical diagnoses as much as it does to poker.

    Dr George Margelis

    http://www.georgemargelis.com

  4. Narelle Kikkert says:

    Well you’ve got anti-vaccination groups foaming at the mouth in glee. They think you are on their side. This article, to them, obviously means vaccinations for any diseases are too much medicine. What do you think of this interpretation Dr Moynihan? I think it would save a lot of confusion if you can please tell us what side of that fence you are on.

     

  5. CKN Queensland Health says:

    I agree, and thank Dr Moynihan for this editorial.  It is always good to be reminded that avoiding overdiagnosis and overtreatment is good medicine, just like vaccinating according to schedule is good medicine.

    It’s not simply ‘medicine is good’ or ‘medicine is bad’.  Rather, careful, calculated use of medicine is a great thing, and indiscriminate use (like whole-body CT’s) can harm.

    Regarding the PSA issue, I think it’s good to remember (according to the epidemiolgical studies) many more lives could be saved by FOB testing than by PSA testing, but FOB testing has far less public awareness, in my mind.  That is a shame. 

     

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