{"id":44244,"date":"2019-03-15T18:24:50","date_gmt":"2019-03-15T17:24:50","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=44244"},"modified":"2019-03-15T18:41:49","modified_gmt":"2019-03-15T17:41:49","slug":"getting-at-the-roots-rather-than-pruning-the-branches-of-overdiagnosis","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2019\/03\/15\/getting-at-the-roots-rather-than-pruning-the-branches-of-overdiagnosis\/","title":{"rendered":"Getting at the roots rather than pruning the branches of overdiagnosis"},"content":{"rendered":"

Healthcare is in a tailspin as the rush to offer technology and services turns otherwise healthy people into concerned patients by identifying disease that is not destined to cause them harm. [<\/span>1]\u00a0<\/span>As described in the many presentations at the 2018 Preventing Overdiagnosis conference, from cancers\u00a0<\/span>to rheumatology,\u00a0<\/span>to incidentalomas identified on imaging tests<\/span>\u2014<\/span>t<\/span>he tree of overdiagnosis branches into many areas of medicine. [2-10]\u00a0 While usually based on well-intended efforts to identify disease at an early stage of diagnosis, it can result in harm when patients undergo treatment that ultimately will not benefit them while exposing them to all the harms associated with the treatment and management. It can also create anxiety, affect quality of life, and in some cases, cause harm to others. [<\/span>11]<\/span><\/p>\n

As the tree of overdiagnosis has grown, efforts have been made to trim the branches. Initiatives such as <\/span>Preventing Overdiagnosis<\/span><\/i>, <\/span>Too Much Medicine<\/span><\/i>, <\/span>Slow Medicine <\/span><\/i>aim to increase our understanding of how it manifests itself. Efforts such as <\/span>Choosing Wisely<\/span><\/i>\u00a0<\/span><\/i>are underway to affect policy and change patient expectations and to change well-entrenched medical practices. [12]<\/span><\/p>\n

The tree of overdiagnosis is rooted in an approach to medical care that seeks to identify pathophysiology, with scant acknowledgement of the role of conditional probability in medical practice. First codified in the United States by the Flexner Report in 1910,<\/span>this rationalist paradigm results in learners prioritizing a strictly pathology-based, disease-focused process for medical decision making, one that makes difficult the shedding of a linear cause-and-effect relationship. [13] The resulting trust in inductive logic, which is fertilized with a combination of activism, defensive medicine, and the overselling of medical care as the solution to many aspects of the human condition, leads to overdiagnosis. <\/span><\/p>\n

Biological plausibility, though, is a necessary, but not sufficient basis for decision-making. This inductive approach needs to be tempered when findings from outcomes trials do not support its conclusions. <\/span><\/p>\n

As any arborist knows, it is easier to train a tree early in its growth rather than attempting heavy pruning after the tree is well established. \u00a0Rather than pruning one branch at a time, we need to address the roots of overdiagnosis by introducing probability-based medicine throughout medical training. At each step in the learning process, the certainty of biomechanical thinking needs to be contrasted with the uncertainty of clinical medicine, the high ground of Sch\u00f6n\u2019s \u201ctechnical rationality\u201d<\/span>\u00a0<\/span>replaced with the swampy lowlands of clinical practice. [14] Every carefully-explained mechanism needs to be clinically correlated with current outcomes-based research. Only then can learners embrace the concepts of overdiagnosis and overtreatment.<\/span><\/p>\n

Many medical schools do provide some training in the basic science of clinical epidemiology, as described by David Sackett and colleagues,<\/span>\u00a0<\/span>along with the principles of Bayes\u2019 theorem. [15] Most students, however, imprinted on a pathophysiologic-based decision making model, lack reinforcement of the inherent uncertainty in the algorithms they learn. [<\/span>16]\u00a0<\/span>In residency education, the pattern recognition that develops needs to be augmented with an understanding of the current evidence supporting the newly-learned scripts, as well as the awareness to know when to question one\u2019s current knowledge and take the time to find, evaluate, and apply the best current evidence. <\/span><\/p>\n

To create future clinicians with the flexibility needed to understand and accept such concepts as overdiagnosis, and how to minimize the harm in perpetuating it, we need to evolve early medical education so that it focuses on the hierarchy of evidence and emphasizes patient-oriented evidence using probability-based decision-making. What ought to work needs to be subordinated to what has been shown to work.<\/span><\/p>\n

 <\/p>\n

\"\"<\/a>Allen F. Shaughnessy<\/i><\/b>, Tufts University School of Medicine, Boston, MA USA<\/span><\/i><\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

 <\/p>\n

\"\"<\/a>David C. Slawson<\/i><\/b>, University of North Carolina at Chapel Hill, Atrium Health, Charlotte, NC USA<\/span><\/i><\/p>\n

Competing interests<\/b>: <\/span>None declared <\/span><\/p>\n

 <\/p>\n

 <\/p>\n

References:<\/strong><\/p>\n

    \n
  1. Brodersen J, Kramer BS, Macdonald H, et al. Focusing on overdiagnosis as a driver of too much medicine. <\/span>BMJ<\/span><\/i>2018;362:k3494. doi: 10.1136\/bmj.k3494 [published Online First: 2018\/08\/19]<\/span><\/li>\n
  2. Dal Maso L, Panato C, Franceschi S, et al. The impact of overdiagnosis on thyroid cancer epidemic in Italy,1998-2012. <\/span>Eur J Cancer<\/span><\/i>2018;94:6-15. doi: 10.1016\/j.ejca.2018.01.083 [published Online First: 2018\/03\/05]<\/span><\/li>\n
  3. Davies L, Petitti DB, Martin L, et al. Defining, Estimating, and Communicating Overdiagnosis in Cancer Screening. <\/span>Ann Intern Med<\/span><\/i>2018;169(1):36-43. doi: 10.7326\/M18-0694 [published Online First: 2018\/06\/28]<\/span><\/li>\n
  4. Jung M. Breast, prostate, and thyroid cancer screening tests and overdiagnosis. <\/span>Curr Probl Cancer<\/span><\/i>2017;41(1):71-79. doi: 10.1016\/j.currproblcancer.2016.11.006 [published Online First: 2017\/01\/21]<\/span><\/li>\n
  5. Rochman S. Thyroid Cancer’s Overdiagnosis Problem. <\/span>J Natl Cancer Inst<\/span><\/i>2017;109(7) doi: 10.1093\/jnci\/djx153 [published Online First: 2018\/07\/10]<\/span><\/li>\n
  6. Brito JP, Hay ID. Thyroid cancer: Overdiagnosis of papillary carcinoma – who benefits? <\/span>Nat Rev Endocrinol<\/span><\/i>2017;13(3):131-32. doi: 10.1038\/nrendo.2016.224 [published Online First: 2017\/01\/07]<\/span><\/li>\n
  7. Breidablik HJ, Meland E, Aakre KM, et al. PSA measurement and prostate cancer–overdiagnosis and overtreatment? <\/span>Tidsskr Nor Laegeforen<\/span><\/i>2013;133(16):1711-6. doi: 10.4045\/tidsskr.13.0023 [published Online First: 2013\/09\/06]<\/span><\/li>\n
  8. Sandhu GS, Andriole GL. Overdiagnosis of prostate cancer. <\/span>J Natl Cancer Inst Monogr<\/span><\/i>2012;2012(45):146-51. doi: 10.1093\/jncimonographs\/lgs031 [published Online First: 2012\/12\/29]<\/span><\/li>\n
  9. Landewe RBM. Overdiagnosis and overtreatment in rheumatology: a little caution is in order. <\/span>Ann Rheum Dis<\/span><\/i>2018;77(10):1394-96. doi: 10.1136\/annrheumdis-2018-213700 [published Online First: 2018\/07\/06]<\/span><\/li>\n
  10. O\u2019Sullivan JW, Muntinga T, Grigg S, et al. Prevalence and outcomes of incidental imaging findings: umbrella review. <\/span>BMJ<\/span><\/i>2018;361 doi: 10.1136\/bmj.k2387<\/span><\/li>\n
  11. Shaughnessy AF, Slawson DC. Moving beyond Flexner: Evolving medical education to stop promoting overdiagnosis. <\/span>BMJ Evidence-Based Medicine<\/span><\/i>2018;23(23):A1. doi: <\/span>http:\/\/dx.doi.org\/10.1136\/bmjebm-2018-111070.1<\/span><\/a><\/li>\n
  12. Ross J, Santhirapala R, MacEwen C, et al. Helping patients choose wisely. <\/span>BMJ<\/span><\/i>2018;361:k2585. doi: 10.1136\/bmj.k2585 [published Online First: 2018\/06\/17]<\/span><\/li>\n
  13. Flexner A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. New York: Carnegie Foundation for the Advancement of Teaching 1910.<\/span><\/li>\n
  14. Sch\u00f6n DA. The reflective practitioner. How professionals think in action: Basic Books 1983.<\/span><\/li>\n
  15. Sackett DL, Haynes RB, Tugwell P. Clinical Epidemiology: A Basic Science for Clinical Medicine: Little, Brown 1985.<\/span><\/li>\n
  16. Sandhu H, Carpenter C, Freeman K, et al. Clinical Decisionmaking: Opening the Black Box of Cognitive Reasoning. <\/span>Annals of Emergency Medicine<\/span><\/i>2006;48(6):713-19. doi: 10.1016\/j.annemergmed.2006.03.011<\/span><\/li>\n
  17. Preventing overdiagnosis: winding back the harms of too much medicine 2018 [September 14, 2018]. Available from: <\/span>http:\/\/www.preventingoverdiagnosis.net\/<\/span><\/a>.<\/span><\/li>\n<\/ol>\n

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