CONTENTS
🟢 Overdiagnosis and the ethics of medical tests
Quick bites
🟢 The centipede’s dilemma
🟢 How worrying about sickness can make you sick
🟢 Second helpings - good reading from the web
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LEAD ARTICLE
Modern medicine has provided us benefits that we often don't fully appreciate. We have to be thankful for living in a time when medical care can successfully treat and restore us from diseases that, even a few decades ago, were commonly fatal. Still, there are areas of dissatisfaction, even anger, from the recipients of care. This article is #1 in a series which addresses these dark spots.
Over diagnosis and the ethics of medical tests
It's magic. The late Arthur C. Clarke, the well-known science fiction writer, said, "Any sufficiently advanced technology is indistinguishable from magic." There can be no arguing about the magical abilities of the tools that we have at our disposal today.
Medicine is no exception. There's no corner of the human body, however small or remote, that can't be imaged or sampled by currently available technology.
There appears to be no slowing down either in the pace with which new technology (diagnostic and therapeutic) is being introduced into medical practice.
Technology, by itself, is value-free; history is replete with examples: the power of the atom being available for peaceful purposes as well as the production of large-scale destruction; the use of the internet for disseminating knowledge on a scale that was never earlier possible while at the same time being used for spreading disinformation and fomenting dissent.
The number of available tests far exceeds the capacity of even the best doctors to fully understand the power and limitations of each test.
Tomfoolery. We glibly assume that new innovations are beneficial and rarely pause to reflect on technology usage in medical practice.
"If you put tomfoolery into a computer, nothing comes out of it but tomfoolery. But this tomfoolery, having passed through a very expensive machine, is somehow ennobled, and no one dares criticise it." (Pierre Gallois)
Overdiagnosis is rampant. Doctors persistently overorder diagnostic tests. Consider this statement made in an article in the British Medical Journal, a prestigious publication.
"Medicine’s much-hailed ability to help the sick is fast being challenged by its propensity to harm the healthy. A burgeoning scientific literature is fueling public concerns that too many people are overdosed, overtreated, and overdiagnosed.“
Moynihan R, Doust J, Henry D. BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3502
Primum non nocere ...? I am no Luddite or technological nihilist, and I am awestruck by the advances in my chosen profession. But the ethics of technology usage involve the examination of issues that are not always apparent. It could be discussed under four poor practices:
1.Too many tests,
2.Done too often,
3.For unproven indications and benefit,
4.Driven by incentivization and commercial influences of a distasteful nature.
1.Too many tests
The fixed menu approach. There is a well-entrenched belief in the public mind that the wider the panel of tests, the greater the likelihood of early detection of diseases. Science does not support this belief. There are only a small handful of tests with proven validity for a given condition. Most of them are simple and inexpensive.
The "panel" approach to diagnostic testing is all too common. Conveniently labelled, they prevent doctors from thinking things through and selecting only the appropriate tests: a haemoglobin and hematocrit estimate rather than a complete blood count (CBC) for checking anaemia; an alkaline phosphatase test alone when screening for liver secondaries in cancer rather than the entire liver function test (LFT) package; and so on. The offered reason behind the panel approach is that of being thorough; in reality, it is wasteful and generates unnecessary expenses without any benefit to the patient.
Annual, “Master Health Checks” are a waste of resources. There is clear evidence that they have little value in early diagnosis. Here’s a post from an earlier edition of {P}rescription that talks about the lack of validity of cancer screening tests.
It is worth pointing out that close to 95% of all tests that are ordered are reported as normal. While it is true that a normal test provides reassurance, certainly the number of normal tests reported is too large to be an accurate reflection of our diagnostic needs.
Test is positive, you are OK. Panel testing, in addition, amplifies the risk of false positive results and the consequences thereof. A common example is the practice of ordering treadmill (stress) ECGs as part of routine health screening in young, asymptomatic individuals. When used in a shotgun fashion, false positives are common. The situation can be laid to rest only by obtaining a coronary angiogram—neither a cheap nor innocuous procedure.
2.Done too often
Tests are repeated to monitor the progression of disease and the response to treatment. Practice guidelines and consensus-based recommendations prescribe optimal frequencies for repeating tests; these guidelines are more often breached than adhered to.
The evidence base, as time evolves, narrows down recommendations. As an example, the traditionally recommended follow-up testing for a woman with early-stage breast cancer who is clinically disease-free after the primary treatment has been carried out included a complete physical examination, a chest x-ray, an abdominal scan, a bone scan, and a mammogram of the opposite breast (and the conserved breast if a breast-conserving option was used). There is mounting evidence that this standard practice has very little value in terms of pre-symptomatic detection and intervention. The only test of value is the screening mammogram. Yet, it is rare to see an oncologist follow this recommendation.
3.Unproven indications
Extending the expectations of a test beyond what is proven and established is unscientific. Still, tests are ordered when there is little basis for their use.
Using tests for screening when there is little evidence in support of their role in presymptomatic detection is a common error. The previously quoted example of a stress ECG in low-risk, asymptomatic populations is a good example. Routine abdominal scans offered as part of health screening packages are likewise unsound recommendations.
Diagnostic technologies have advanced to the point where very small abnormalities can be picked up. A case in point is the chest x-ray, the workhorse of radiology for almost a century. Though simple and easily available, it can pick up abnormalities only after they reach a certain size. In lung cancer, the chest x-ray detects the disease at stages that are often too far advanced to be treatable for cure. The CT scan is far superior, though much more expensive. There can be too much of a good thing when used for early diagnosis. Many of the abnormalities detected by CT scanning have no clinical consequence. However, a lot more effort and expense will be involved in laying the issue to rest.
Recommendations and guidelines are often drawn up by panels made up of groups with conflicting interests. What comes out is often a consensus of the ill-informed, more concerned about political correctness than scientific validity. People supported by Big Pharma frequently make up panels.
In loco parentis. The patient, however well informed, is in no position to make these decisions. The physician has a clearly fiduciary role in this regard and has to commit herself to the constant need to avoid unnecessary technological interventions.
4.Incentivisation and commercial practices abound
The price of standard diagnostic tests will vary very little between facilities in a given geographical area, although the overall hospital bill may show significant variability for identical transactions. Market forces, in an open economy, permit very little room to move in terms of the amount that can be charged for easily available diagnostic tests. The marketplace mandates a modicum of restraint with respect to the limits on charges.
In business, volumes are achieved by two strategies: increasing market share and increasing utilization. In medical practice, market share is hard to enlarge unless the organisation has a widely known brand image. To counter this restriction, the only business model left for those who invest in today's healthcare technology is one of pushing for more utilisation: profits depend on volumes and very little else. In an effort to increase usage, incentives and kickbacks are offered. Under no circumstances can such practices be condoned. Accepting a commission or kickback is an inexcusable breach of the fiduciary trust that a doctor bears for his patient.
That hurts — I mean the bill. Despite its benefits, healthcare today is more expensive than it has ever been. Even in developed societies, families are driven to bankruptcy by hospitalisation costs. A critical approach to diagnostic testing will go a long way towards controlling expenses that burden patients today.
▶️ The centipede’s dilemma: Why overthinking is killing productivity
🔽 “Quick bite” - click on the excerpt below to view my notes from this post
🇪🇳🇩🇶🇺🇴🇹🇪
💬 “Don't get too deep, it leads to over thinking, and over thinking leads to problems that doesn't even exist in the first place.” ― Jayson Engay
💬 “The sharpest minds often ruin their lives by overthinking the next step, while the dull win the race with eyes closed.” ― Bethany Brookbank
▶️ Health anxiety can be all-consuming. Accepting uncertainty is an important step
🔽 “Quick bite” - click on the excerpt below to view my notes from this post
🇪🇳🇩🇶🇺🇴🇹🇪
💬 “Each person must develop a wholesome personal response to enduring the hardships of daily life and witnessing the discord, disharmony, dissension, and suffering of the world. … How we respond to the vale of tears until we shuffle off this mortal coil imbrues poetic meaning to our life.” ― Kilroy J. Oldster
SECOND HELPINGS
Good reading from all over
Begging the question (Petitio Principii): Fallacious circular reasoning (one of the most commonly misused phrases in writing)
Why you should start every day by accomplishing one small task
Welcome to the ‘golden age of medicine’ (plus, seven big breakthroughs)
Physics has long failed to explain life – but we're testing a groundbreaking new theory in the lab
A very true analysis by an expert about current health care status!
By the time patient presents to a (true) specialist, most of their resources are drained. Say for eg., a person with lung mass with supraclavicular node has everything in hand (PET, CT Abdomen etc.,) except a simple lymph node biopsy which would have yielded both diagnosis and staging instantly