{"id":32629,"date":"2014-10-29T14:08:53","date_gmt":"2014-10-29T13:08:53","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=32629"},"modified":"2015-09-22T14:33:47","modified_gmt":"2015-09-22T13:33:47","slug":"william-cayley-overdiagnosis-uncertainty-and-epistemology","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2014\/10\/29\/william-cayley-overdiagnosis-uncertainty-and-epistemology\/","title":{"rendered":"William Cayley: Overdiagnosis, uncertainty, and epistemology"},"content":{"rendered":"

\"bill_cayley_2\"<\/a>Many thanks to Anita Jain for reporting on the \u201cOverdiagnosis\u201d session<\/a> at the Cochrane Colloquium\u2014I wish I could have been there.<\/p>\n

The suspicion that overdiagnosis (or at least over testing) is driven in part by the quest for certainty, is corroborated by an implementation study of the Vancouver chest pain rule<\/a>. When the Vancouver chest pain rule was implemented<\/a>\u00a0as a triage protocol, the number of patients presenting for emergency care of acute chest pain who could subsequently be discharged early for outpatient follow-up was almost doubled.<\/p>\n

Thus, rational use of a clinical prediction rule, rather than testing based on convention or habit, allowed for equivalent care with less testing and lower utilization of resources. Put another way, providing a valid mechanism to reach a level of diagnostic certainty can also help reduce over utilization.<\/p>\n

Unfortunately, the promotion of rational testing may be undermined by other factors, including who owns the testing. When talk of the \u201cprofit motive\u201d in medicine arises, it is easy to blame industry or even \u201ccorporate medicine,\u201d but the problem may lie with us as doctors as well.<\/p>\n

It turns out that the more equipment we own, the more we are likely to use it – a 2004 article in the Journal of the American College of Radiology<\/em> estimated that self referral for imaging<\/a> by non-radiologists cost the US\u00a0Medicare system at least $16 billion every\u00a0year (and that was 10 years ago). So, \u201cif we own it, we will use it\u201d\u2014how often have you done a test \u201cbecause it was there,\u201d even though in the end it made no difference to your management? This is not to say that all self referral for in office imaging (or other investigations) is purely out of avarice or greed, but the easier a test is to obtain, the more likely we are to do it\u2014even if, in the end, it makes no difference to our clinical decisions.<\/p>\n

Fundamentally, though, both of these drivers of overdiagnosis and over testing have to do with a common underlying theme: dealing with uncertainty. Anita concluded with the story<\/a> of \u201ca brave young doctor (who) shared how uncomfortable the session had made him feel . . . \u201d because throughout his training, \u201cthe focus had always been on picking up the signs of disease and reaching a diagnosis.\u201d A change in methods or philosophy or paradigm is bound to make one uncomfortable, as it may challenge one\u2019s basic epistemology.<\/p>\n

In an interesting 2009 study, Trotter and colleagues found that<\/a>, \u201camong primary care physicians, a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty.\u201d In a subsequent study with medical students<\/a>, they found that the third year student (i.e. the beginning of clinical work in US medical training) \u201cis an opportune time for medical educators to help shape and develop students’ medical epistemology and stress reactions to uncertainty.\u201d<\/p>\n

In short, it appears that the more well rounded we are, the better equipped we may be to deal with the tensions of uncertainty, possibility, and partial knowing\u2014instead of pursuing more and more detail that may add little or no benefit to our patients\u2019 care.<\/p>\n

How does one promote a more \u201cbiopsychosocial\u201d epistemology? How does one promote increased capacity for dealing with uncertainty? To paraphrase Shakespeare<\/a>, \u201cThat is the question!\u201d<\/p>\n

Several blogs have recently promoted the place of literature in medicine, from David Payne\u2019s \u201cBooks for the incurably curious<\/a>” to Suchita Shah\u2019s exploration<\/a> of why we need literature in medicine. Cross cultural experiences, promotion of diversity in the workplace or the training setting, and active engagement of patient perspectives are other avenues that may hold promise for promoting an expanded, more biopsychosocial epistemology, with better tolerance for and appreciation of making decisions in the face of uncertainty.<\/p>\n

To again paraphrase Shakespeare<\/a>: \u201cThere are more things in Heaven and Earth, Horatio, than are dreamt of in your philosophy.\u201d<\/p>\n

William E Cayley Jr<\/strong>\u00a0practices\u00a0at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.<\/em><\/p>\n

Competing interests: I declare that I have read and understood the BMJ policy on declaration of interests and I have no relevant interests to declare beyond my work as books and media review editor<\/a> for Family Medicine<\/em> and my passion for reading.<\/p>\n","protected":false},"excerpt":{"rendered":"

Many thanks to Anita Jain for reporting on the \u201cOverdiagnosis\u201d session at the Cochrane Colloquium\u2014I wish I could have been there. The suspicion that overdiagnosis (or at least over testing) […]<\/p>\n

More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5756,1357,14769],"tags":[],"class_list":["post-32629","post","type-post","status-publish","format-standard","hentry","category-too-much-medicine","category-us-health-care","category-william-cayley"],"yoast_head":"\nWilliam Cayley: Overdiagnosis, uncertainty, and epistemology - The BMJ<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmj\/2014\/10\/29\/william-cayley-overdiagnosis-uncertainty-and-epistemology\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"William Cayley: Overdiagnosis, uncertainty, and epistemology - The BMJ\" \/>\n<meta property=\"og:description\" content=\"Many thanks to Anita Jain for reporting on the \u201cOverdiagnosis\u201d session at the Cochrane Colloquium\u2014I wish I could have been there. 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