Saturday, 20 October 2012

Help! I've been overdiagnosed.

Every doctor fears a complaint. And particularly when the complaint is about delayed diagnosis. Thankfully I haven't received such a complaint yet, but I'm not complacent. What has yet to happen, but I suspect will not be far away, is the patient who formally complains that the doctor has over-diagnosed.

When a condition that probably would not have harmed the patient, nor affect life expectancy, is diagnosed, the consequences are not small. There is the resulting stress of tests and treatment,  endless hours in waiting rooms, medication-which may have side effects, or surgery, which too may have adverse effects. And the anxiety associated with uncertainty of prognosis. And all for what?

A growing body of medical opinion is trying to do something about the situation-but it's a mammoth task.  In a very helpful article from the 5th June 2012 BMJ (subscription needed), the authors delineate the 'drivers of over diagnosis'

Thanks to the excellent Margaret McCartney, a female blogging GP from Glasgow, I became aware of a  new website  launched recently with the  aim of informing of the 'dangers' of screening. There are so many competing interests at work.
  • Technological changes detecting ever smaller “abnormalities”
  • Commercial and professional vested interests
  • Conflicted panels producing expanded disease definitions and writing guidelines
  • Legal incentives that punish underdiagnosis but not overdiagnosis
  • Health system incentives favouring more tests and treatments
  • Cultural beliefs that more is better; faith in early detection unmodified by its risks
In a recent salutary article for the New York Tines, a woman with a black eye recounts her story,
Sometimes the toll of too much medicine is brief, but emotional. Kara Riehman, 43, of Atlanta was vacationing in California when she lost a struggle with an ironing board in her hotel room and ended up with a black eye.As the bruising peaked around 10 days, she called her doctor to make sure everything looked normal. But instead of seeing her, the doctor, through a conversation with the nurse, ordered a CT scan. She had no symptoms other than a bruised eye, but the doctor never spoke with her or examined her.  
The scan came back with an ambiguous finding, and the nurse told her it could be a tumour. She was then given an M.R.I. and for two weeks while she waited for the results, she worried she had brain cancer.  The nurse called to tell her the M.R.I. was fine.
“It was really terrible,” she said. “It was only two weeks, but there is a lot of cancer in my family. I never actually talked to my doctor through this whole thing.” 
The total cost to her insurance company was about $7,000. “It did change how I think about interacting with the medical system,” Ms. Riehman said. “It made me much more of a questioning consumer.”
This issue isn't going to go away. Indeed with pressure for GPs to prescribe according to guidelines, which take no account of what other medication the patient may already be on, and the lack of guidelines helping us make decisions about when to stop medication, we're facing the twin dangers of over treatment as well as over diagnosis.
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