American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tuesday, October 15, 2013

What is "overdiagnosis"?

I got an invitation in my e-mail a couple of days ago for a dinner presentation to the Central Oregon Medical Society given by H. Gilbert Welch, MD, on the subject of overdiagnosis. I was intrigued. A little less than a year ago Dr. Welch, an internist and professor at Dartmouth Medical School and Archie Bleyer, MD, a former pediatric oncologist and now a research professor at Oregon Health and Sciences University wrote a controversial article presenting compelling evidence that regular mammograms lead to death and disability related to aggressive treatment in many of the patients who were diagnosed with breast cancer but that it did not significantly improve survival.

Dr. Welch has been studying overdiagnosis for a couple of decades and has written two books, Should I Be Tested For Cancer?: Maybe Not and Here’s Why and Overdiagnosed: Making People Sick in the Pursuit of Health. I have peeked at the second one and found it to be well written, with a non-physician audience intended.

Overdiagnosis is defined as detecting disease in patients without symptoms which, if undetected and untreated, would lead to no harm. This is not a good thing. People who find that they have a disease often use more resources, get more testing and treatment with associated costs and side effects, and feel worse about their health. In the small picture, this is caused by increasingly sensitive screening tests, more strict definitions of normal and increased use of imaging procedures which see things we weren’t even looking for.

It has been pretty well established for breast cancer screening and for thyroid imaging, which detect low level cancers which probably would never progress, and for prostate cancer, for which in most cases the treatment is worse than the disease, and the disease is extremely common. It also appears to be true for kidney failure, which has been diagnosed more and more commonly in elderly people despite the fact that we know their kidney function normally declines with age. Overdiagnosis occurs when we remove colon polyps which had no malignant potential during excessively frequent colonoscopies and when we screen ancient and dying people for cancers which would never contribute to their inevitable demise.

Overdiagnosis is estimated to result in many, many billions of dollars of excess health care spending.

In the big picture, overdiagnosis is caused by the economics of our medical system: defining more people as sick increases use of medical care which keeps doctors and staff and the many industries that serve us and our patients in business. The patients who are overdiagnosed are also not very sick, or not sick at all, so they are easier to treat, mostly. It’s a win/win situation. Except that it isn’t.

Reducing our thresholds for defining disease is not entirely a bad thing, though. We have gradually reduced the blood sugar at which we diagnose a patient with diabetes. It turns out that slightly elevated blood sugars are nearly as predictive of bad outcomes as higher blood sugars. It has been my experience, as well, that patients who are told they have diabetes often immediately take seriously their needs for lifestyle changes, so they begin eating more healthily, exercising and losing weight which is undeniably good for them.

September 10-12, 2013 is the first ever conference on overdiagnosis at Dartmouth University, in which there will be talks about the extent of the problem and then discussion of ways to roll back excesses. Already there has been a conference on Selling Sickness which involved activists of many descriptions who came up with some resolutions to reduce “disease mongering.” These include improving research to determine what tests and treatments are actually effective and separating funding for this from parties whose economic interests would benefit from positive results. The American College of Physicians and many specialty organizations have gotten behind the “Choosing Wisely” campaign which targets tests, procedures and treatments which are without proven benefit, though they may be widely practiced.

When we, as doctors, think about it, we don’t want to be doing things that are of no particular benefit to our patients, even if it does give us job security. It makes us feel that our jobs are meaningless and it puts us at odds with the people we treat. We have been expanding our scope this way for so long, though, that it takes a while to change gears, and communication and education has to be excellent in order that we come to consensus. Many of us think we will be sued if somebody develops a condition that we could have screened for, even if that screening rationally would not have made a difference in their outcome. We need good solid support for curtailing our excesses.

Central Oregon is a long way away from where I am, a good 7-plus hour drive, and the talk is only a couple of hours long, so I think I’ll just read his book and read the articles that come out of the Dartmouth conference. If doctors who are well respected put their energy into this effort, good will come of it. I’m proud of us for trying.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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