Issue 32 / 26 August 2013

CONSIDER this paradox: at a time when we have the best access to health care and greatest longevity ever, we seem, as a population, to be more dissatisfied with our health care than ever.

As a general community, we complain about waiting times and waiting lists, we see vested interests everywhere and we perceive our health care system to be in crisis.

As a professional community, we see widespread dissatisfaction, strained resources and strained relationships.

Yet, by any objective measure, preventive and acute medicine are more successful than ever. Vaccination has transformed childhood illness, blood pressure treatment and anticoagulation have minimised stroke, and even asthma in children is on the decline.

Why, then, are we so dissatisfied?

Apart from rising expectations and risk aversion, there is another element at play here that I call “diagnosis creep”.

Where I work, one of the most common presentations is chest pain. Patients presenting with chest pain which could be cardiac are treated as urgent and high-risk until proven otherwise. This makes sound sense in the setting of a possible acute myocardial infarction (AMI), where early revascularisation makes a big difference to outcome.

With better medical care, secondary prevention, smoking reduction and blood pressure control we should be seeing a drop in the number of cases, right?

The fact is we are not doing fewer chest-pain work-ups, we have just shifted our attention to a lower risk group. Of all patients with chest pain admitted for work-up, only a small percentage are found to have AMI.

In these days of high-sensitivity troponin, “troponitis” has become a surrogate for AMI.

Once a non-ST-segment-elevation MI (NSTEMI) meant the electrocardiograph showed ST depression with raised cardiac enzymes. Now patients can be diagnosed with NSTEMI just on the basis of raised enzymes, there may not be coronary occlusion, and the risks and prognosis are not the same as what we used to call AMI. This is diagnosis creep.

Consider also the child with fever. We once worried about Haemophilus influenzae type B (HIB) — now all but vanished with vaccination. We did all those blood cultures for so-called “occult bacteraemia” (wondering if the entity even existed). With pneumococcal vaccination increasing, even this is on the way out. Similarly, few kids today get measles or mumps, or even chickenpox.

So, do we worry less about the febrile child? Well, no. We still do tests, swabs, observation — “it could be a urinary tract infection”.

This issue was recently covered in a study that looked at the publications of recent national and international guideline panels making decisions about definitions or diagnostic criteria for common conditions in the US.

What did they find? Almost all of the groups recommended changes to disease definitions that increased the number of individuals considered to have the disease. Some included a definition of “pre-disease”. None considered the potential harms of widening the definition, of making previously “well” patients ill.

Perspective is needed. If we’re getting sick less and living longer, we are probably, as a society, doing OK.

As they say on the UK Underground, “Keep calm and carry on”.
 

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.

 

11 thoughts on “Sue Ieraci: Diagnosis creep

  1. Paul Koch says:

    One of the most frustrating and recently promoted diagnostic creeps is “dehydration”.

    People assume that because a child has vomtied twice in 30 minutes and had one loose bowel motion that they are severely dehydrated. Real dehydration happens in Africa- try walking for 3 days to the nearest UN aid station when all your family has cholera and 4 of your 6 children die before they reach the aid station- that’s real dehydration.

  2. University of Tasmania says:

    Exactly!  My personal beef is the trend to doing more and more investigations (especially highly detailed medical imaging) with minimal clinical justification .  Do enough investigations and invariably there will be some “suspicion” or “possible” abnormality or more commonly a lab result that falls outside the “normal” range.  Of course these demand futher investigation to determine if the first result is truly significant.  Thus we proceed down the spiral of increasingly complex, expensive and invasive tests.  Plenty of scope for “diagnosis creep”, blowing out health costs, increasing patient anxiety and generating imagined illness.

  3. Charles Darwin University says:

    To Anonymous complaining about over-diagnosis of “dehydration” in children with gastroentertitis, I’m afraid that my experience in Alice Springs has been that people consistently under-diagnose the level of dehydration, especially where there is concurrent malnutrition. Your statement implies that severe dehydration only happens in Africa due to cholera, but we see plenty of children here with severe dehydration due to rotavirus, even in an almost fully vaccinated population. As you posted anonymously, it is not possible to know what your local patient population is like, but I would ask you to please refrain from making such comments that may have a deleterious effect on people treating gastroenteritis in children.

  4. Bryan Walpole says:

    Well written Sue, I date from the days (  graduating in 1967) of exciting medicine, when multiple trauma, meningitis, G-ve sepsis, pneumonia and and shocky ST elevation AMI were weekly or daily events, with a few resus cases a day, now all that has been banished, and a wonderful tribute to public health advances, as you rightly state.

    But now, in emergency medicine we are a continuity managers,  (who mainly won’t look after themselves) with limited community and occasionally inpatient services. Much of the care provided is short term support.

    Hemmed in by guidelines (aka protocols) I can’t use clinical judgement discharging low risk chest pain without troponins, febrile children without tests, elderly women dizzy or falling over (rarely anything serious wrong), headaches backaches (without CT),  sore ankles and wrists (rarely broken, but most need or demand to be x-rayed). Add in the second opinion for the harried GP dealing with uncertainty. Almost all the above will get better regardless of the care provided, but the public, through “Diagnosis creep” perceive medical care essential, and hospital the place to dispense it .

    Do all those people over 50 (40!) benefit from lipid lowering drugs? Are cardiac stents (at $2000 each) really as effective as good healthcare? Are lapbands the only effective cure for adolescent morbid obesity? Do those fingertips caught in the car door do better with plastic surgery than a good wash and a dressing? Vast numbers are taking near useless psych drugs for personal social dilemmas.

    As I shift from sceptic to cynic, it’s time to get out of medicine, as I now stand in the way of progress, and a hazard to the new graduate.

     

  5. Ben Physician says:

    Well written Sue. 

    Is this as much a condition of a litigious society and a lack of political will power (i.e. backbone) of those high up on the health care food chain?

    To have a sensible approach to clinical management, treating physicians need to also get a sense of support and security that they have the backing of the hospital bosses (and legal departments). Patient expectation needs to also be managed.

    No easy solution and I think the issue is driven by powers outside of the medical community per se?

  6. Kal Fried says:

    This is a major problem in musculoskeletal / sports / othopaedic medicine with clinical medicine concepts such as “treat the patient not the scan” and “do no harm” becoming extinct. The current widely accepted paradigm is simply –> PAIN + SCAN FINDING = INTERVENTION (often a surgical attempt to “fix”). Research confirmimg the vast number of asymptomatic positive scan findings and total lack of correlation between most scan findings and levels of pain and disability is being completely ignored by a voracious interventional apetite. Patients are fed misinformation which creates unnecessary fear and anxiety and chronic pain is escalating at significant rates despite (and maybe because of) all this wonderful technology and increasing surgical and other interventions. Mix this situation with compensation and adverse motivational factors, and we have the perfect storm. Diagnosis creep as you describe it, or simply over-medicalisation as I describe it, is likely leading to greater iatrogenic* problems rather than a healthier society, compounded by the issue of valuable health dollars diverted to these processes. I’m with you Bryan Walpole bemoaning the demise of sensible clinical medicine, but retirement is still some way away for me!!

    * eg: Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open 2013 Apr

     

     

     

  7. Lisa Walsh says:

    You’re sounding like my son’s soccer team. They preferred last season in Division 2 (lots of easy, effortless wins) to this season in Division 1 (far more effortful and challenging, demanding practice and skill).

    Granted some consults may be monotonously mundane, but catching disease in its early stages demands diagnostic skill and more effort to keep uptodate with research.

    For example:

    Failing to dx and treat shingles (esp. without rash) can lead to chronic post-herpetic neuralgia, a seriously debilitating condition.

    Dismissing perimenopausal symptoms as temporary/normal when impaired sleep, sexual dysfunction, or extreme irritability which can precipitate serious family conflict or quitting work if the need for HRT is neglected.

    Missing an introverted child’s issues, eg enuresis, anxiety or depressive symptoms as being symptoms/sequelae of the inattentive presentation of AD/HD. This disorder left undiagnosed and untreated always leads to school underachievement and often social and mental health problems, and to being more prone to accidents, teenage pregnancy, and developing addictions or personality disorders and criminality. If a child is dx with ADHD by dev paed, DO highlight to parent/s that ADHD is highly heritable (over 80% concordance) because disordered self regulation and emotional dysregulation lead to likely problems adhering to medication treatment. What these parents deem normal is often not normal and they very often appreciate genuinely concerned questioning about this possibility. It should also be ruled out in siblings.

    What’s boring about preventing disease from escalating into more intractable conditions which can also have devastating social consequences?

  8. Flemming Nielsen says:

    Well said Sue. I have been working with children since 1984 in Africa. They have never been as well and parents have never been as worried about fever usung Neurofen to “fix” it in spite of it NOT being recommended in dehydration, UTI renal conditions Influenza, Asthma ITP, bleeding disorders. The diagnosis and pill popping society is growing forever more worried, such a pity. Children are actually so healthy. Chances of dying from infection in australia between age 1 and 14 less than 1 in 200 000 now (excluding aboriginals APLS). The TV advertising is much stronger than doctors advice.

  9. Sue Ieraci says:

    Elisabeth – I’m not sure we are discussing the same issue. I’m not suggesting we put less effort, practice and skill into diagnosis and decision-making, but MORE. We need to go right back to pathophysiology. In the chest pain example, management aimed at urgent re-vascularisation for acute coronary occlusion is not suitable for the elderly person with sepsis and compromised tissue perfusion – though both situations might result in a raised troponin. In fact, all of the examples you have described require careful history-taking and insight – not just test results. In a sense, that’s my point.

  10. Fiona Dobson says:

    Hi Sue,

    Thank you for your comments on the Conversation regarding fluoride. They are really timely and insightful.

    I wish there were more like you to help me fight the anti fluoride whackos.

  11. Diane Campbell says:

    Excellent post Sue.

    My main problem with tropinitis in PE and pneumonia patients (usually found by a “clinical initiatives” nurse inappropriately applying a chest pain nurse-initiated-protocol to an older patient with fever and cough!) is that it provides an excuse for wards to reject patients as “needing a monitored bed” and these patients remain in DEM, to the detriment of their own care and that of other patients.

    The shift of resources is a very real problem with overdiagnosis. A family with a severely autistic 10 year old who has not learned to speak or communicate, and who attempts to kill the new baby, needs all the support they can get. Yuppie mums who decide that autism is the new dyslexia try to get that label on their offspring so that they can have a share in any additional resources allocated to the school to assist with autistic or otherwise disabled children. [Diane Campbell]

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