‘Too much medicine’ in medical training

Not surprisingly, for most medical students I have taught, “overdiagnosis” comes as a fairly new concept.  Rather, the emphasis is more on not missing a diagnosis or ordering a test. While many factors may have influenced this common mindset, it’s crucial that all aspiring physicians are aware of the well-known harms of “too much medicine”.

Strong evidence is mounting that in our enthusiasm to treat disease we may be actually doing more harm than good. Overdiagnosis – the diagnosis of a disease which will not lead to symptoms or cause death during a person’s life time – is being increasingly considered as a modern epidemic in medicine.

Rightfully so – an estimated 500 000 people were overdiagnosed with thyroid cancer across 12 countries in the past two decades, while around 30% of Australian women with breast cancer – and 20-50% of US men with prostate cancer – were found to be overdiagnosed.

These “patients” – now labelled with a “diagnosis” of doubtful benefit – may then be subjected to further investigations and treatment (that is, overtreatment) which are often unnecessary and harmful.

In a wider health system perspective, overdiagnosis leads to overuse, straining the already limited health budgets and challenging the sustainability of health systems. For instance, in US, the national expenditure for breast cancer overdiagnosis and false positive mammograms was estimated at US $4 billion per year.

 

What drives overdiagnosis?

In our recent review in the British Medical Journal we provided the first comprehensive analysis mapping the drivers to potential solutions for overdiagnosis and related overuse. We discussed these across five broad domains: culture, health system, industry and technology, health professionals and public (and patients).

Key drivers of overdiagnosis and overuse (reproduced from Pathirana, T., Clark, J., & Moynihan, R. (2017). Mapping the drivers of overdiagnosis to potential solutions. BMJ, 358, j3879.)

Overdiagnosis may spur from the current methods of teaching and assessment in medical education. For instance, problem based learning (PBL) – as well as clinical assessments – expect (and reward) medical students to come up with the most comprehensive list of diagnoses followed by a good list of investigations for a given clinical scenario.

After graduating, medical trainees continue to work in environments (particularly in tertiary teaching hospitals) where restraint is discouraged and errors of omission (a patient is harmed because a necessary test or treatment was not provided) are penalised more than the errors of commission (a patient is harmed because an unnecessary test or treatment was provided).

At times, their lack of confidence in clinical decision making and fear of litigation may further complicate the picture, while the ready availability of advanced diagnostic technology may further predispose overdiagnosis and overuse in these settings.

 

What are the potential solutions?

In Canada, medical students and residents work in collaboration with Choosing Wisely Canada, which is a national campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, to make effective care choices.

It is part of a global movement that began in the United States in 2012, which now spans 20 countries – including Australia.

The Students and Trainees Advocating for Resource Stewardship (STARS) is a student-led campaign seeking to change the culture of medical education in Canada by addressing the behaviours that can lead to unnecessary care including overdiagnosis and overtreatment.

Based on national surveys of medical students and residents, STARS has published lists of recommendations on how medical students and residents could effectively be involved in reducing unnecessary care, shown below.

Six Things Medical Students and Trainees Should Question’

Five Things Residents and Patients Should Question’

In their paper in JAMA, Dr Allan Detsky and his colleague Dr Amol Verma highlighted the need for clinician teachers to be role models in practising and rewarding restraint, and encouraging resource stewardship where appropriate. They argued that “the merits of rewarding exhaustive medical knowledge are clear, but teachers must be wary of the implied lesson of doing so.”

Around the world, strategies to mitigate overdiagnosis continue to evolve. In August this year, major influential professional and consumer organisations in Australia launched a national action plan to address the problems of overdiagnosis and related overtreatment. This statement highlighted the urgent need “to better inform consumers, clinicians, decision-makers and the public about the evidence for, and the consequences of, overdiagnosis and related overtreatment, as part of a broader approach to inform people about the potential harms, as well as the benefits of medical tests and treatments”.

Thus, indeed the time has come to think twice: Does this patient actually need this diagnosis or treatment? Or would they be better off without it?

Dr Pathirana (MBBS, MPH) is a teaching Fellow and PhD Scholar at Bond University, Queensland, Australia.

The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.