"too much testing of well people and not enough care for the sick – worsens health inequalities and drains professionalism, harming both those who need treatment and those who don't." - Margaret McCartney
A growing frustration of clinical medicine is that we are now so busy managing the proliferation of risk factors, incidentalomas, and the worried well that we lack sufficient time to properly care for the seriously ill. As we expand the definitions of psychiatric disorders, diabetes, kidney disease, and coronary risk, those in crisis are lost in outpatient queues expanded by those who now find themselves on the wrong side of a shifted biochemical boundary. Too much medicine is harming both the sick and well. Much of the growth in apparent illness has occurred by stealth. One striking example is the tripling of the incidence of thyroid cancer - in the USA, Australia, and elsewhere – while the mortality has not changed. This apparent increase is best explained by our improved diagnostic tools, such as imaging, rather than a real change in cancer incidence, but this has had no impact of death from thyroid cancer. Similar “epidemics” have occurred in areas where we have been more deliberately screening, such as breast and prostate cancers. But perhaps the largest growth has been in the disorders where we have changed the definition of who does and doesn’t have the condition: for conditions with where there is no clear dividing line between normal and abnormal, such hypertension, diabetes, osteopenia, and obesity, small changes in the boundaries have greatly expanded the proportion of the population with those disorders.
Changes are need at both health policy and clinical levels. The policy changes needed will include the who and how disease definitions are changed: currently there are no agreed standards on the constitution of panels adding or altering the definitions of diseases, nor are there clear criteria for when it is reasonable to change disease definitions. What can clinicians do? Besides maintaining a healthy level of skepticisms, there are some specific strategies that may be helpful before, during, and after the investigation and labeling of patients. To minimize the chances of over-detection and incidentalomas, investigation and screening should be very selective and targeted. Unexpected abnormal findings should be integrated with the clinical picture, and generally repeated or otherwise verified before diagnosis. If a diagnostic label is necessary, then we should choose carefully and leave it open for reconfirmation. We should be particularly careful not to label risk factors as diseases, for example by talking with patients about raised blood pressure not "hypertension"; "reduced bone thickness" not "osteoporosis"; "reduced kidney function" not "chronic kidney disease". Finally, we need to improve at sharing the information and consequences of options with the patient - a shared decision making approach.
Paul Glasziou FRACGP, PhD is Professor of Evidence-Based Medicine at Bond University and a part-time General Practitioner. He was the Director of the Centre for Evidence-Based Medicine in Oxford from 2003-2010. His key interests include identifying and removing the barriers to using high quality research in everyday clinical practice. He is the author of six books related to evidence based practice: Systematic Reviews in Health Care, Decision Making in Health Care and Medicine: integrating evidence and values, An Evidence-Based Medicine Workbook, Clinical Thinking: Evidence, Communication and Decision-making, Evidence-Based Medicine: How to Practice and Teach EBM, and Evidence-Based Medical Monitoring: Principles and Practice. He has authored over 160 peer-reviewed journal articles and his h-index is currently 43. He is the recipient of an NHRMC Australia Fellowship which he commenced at Bond University in July, 2010.