Pre-Osteoarthritis: Do we really need another "Pre-" disease?

This Spring, Dr Annemarie Jutel (RN, BPhEd(hons), PhD) from the Victoria University of Wellington shared with m some of her work on Social Issues in Diagnosis.

Dr Jutel is a social theorist and clinician interested in finding an understanding of just how diagnosis works, whether from the historical, linguistic, social, literary, clinical, or other angle. 

She explained: 

I am most interested in the “diagnostic moment” and the power of the diagnostic utterance; there is nothing that fundamentally changes in your soma from the moment you walk in to the doctor’s rooms, and the moment you get your diagnosis, but at the same time, if the diagnosis is a difficult one, everything has changed. 

I started following her posts on the Facebook Group, Social Issues in Diagnosis, which explores why and how we create these labels and what impact they have on patients and the course of medicine.

The most recent post is about pre-diagnosis, stimulated by this 2015 paper in Cartilage. If we can detect osteoarthritis before it starts, maybe we can stem the epidemic. Or, maybe we can turn a bunch of healthy, naturally aging, well-people into frightened patients?

In response to the article, Jutel asks:

What is a prediagnosis and what are its consequences? 

If pre-diagnosis states are, potentially, windows of opportunity, wherein individuals can adopt healthy, disease-avoidance behaviours, is there an advantage to calling these states "pre-whatever" as opposed to identifying them as healthy states, wherein health can be further improved?

What are the consequences of being given a pre-diagnosis? For some it may be a scary moment which marks their identity forever more. For others, it may be a wake-up call.

What would it be for you?

Take a look on the FB Group to participate or to learn more, see her book, Social Issues in Diagnosis.

Source: http://www.ncbi.nlm.nih.gov/m/pubmed/26175...

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...

BCMJ Book Review: The Patient Paradox: Why sexed-up medicine is bad for your health

At the Preventing Overdiagnosis conference last year in Oxford, I heard Dr Margaret McCartney speak. This is a passionate woman, one who advocates tirelessly for patients and follows the motto "Think critically and demand evidence." She is an outspoken leader, holding the NHS, her patients, her peers, and herself to high standards, eschewing conflict of interest and junk science.

I was lucky to meet her and when we talked further, Margaret handed me a copy of her book, The Patient Paradox: Why sexed-up medicine is bad for your health. Travel and work got in the way of me opening it, but when I did, I devoured it, underlining and folding and marking key points that resonated with me.

I have read many essays and a few books in the area of "too much medicine," and agreed with most of what they had to say. This book was different. It gained my trust by talking about things I already knew and accepted (more is not always better in medicine) and pushed me just outside my comfort zone, to question things I take for granted (eg the importance of pap tests). I admire the bold way in which she can push the already skeptical to challenge assumptions we didn't even know we had. Since I felt the need to share this book with others, I wrote it up.

You can read my piece about the book and its message in the July/August copy of the British Columbia Medical Journal (BCMJ).
 

You can buy the book from the publisher, Pinter and Martin here. If you want to read other reviews or get a copy on Kindle, Amazon.ca can help.* 

If you like the idea of reading more on the subject of "Less is More in Medicine," there are about 20 books in the Read section of the site, ranging in focus from cancer screening or overdiagnosis in psychiatry to patient-centered care, achieving evidence-based medicine, and turning healthy people into sick.

 

 

 

* I don't receive any kickbacks here, just hoping to make it easy to get the book in your hands

Source: http://www.pinterandmartin.com/the-patient...

Day 1 of Road to Right Care #Lown2015 Recap

What a great day!

Hundreds of mainly American (I am one of 4 Canadians here) doctors, patients, nurses, health administrators, and other health providers gathered today for the first of three days on the Road to Right Care Conference, put on by the Lown Institute.

Being in a room with so many like-minded individuals is invigorating but also offers hope that together, we can actually do something radical.

Main Themes:

  1. Patients and their families and advocates must be at the centre of this movement; young health care providers are the future of this and must be engaged early in their training
  2. Health care is not about consuming, being sick; most of what we do in medicine has no impact on health; health care should be about being well, and about people not diseases:
    “A good physician treats the disease, the great physician treats the patient who has the disease.”  - DR. WILLIAM OSLER

  3. Social determinants of health, especially poverty must be addressed for greatest impact:
     "I can cure homelessness. You just house them and it's cured. Completely curable problem." - DR. MITCHELL KATZ

  4. Our system must be radically transformed; we have many ideas but they boil down to the fact that HIGER QUALITY CARE leads to LOWER COST

  5. Barriers to improvement: financial conflicts of interest, profit-based systems, not listening to what patients really want (eg. independence)

  6. Things that will help us achieve RightCare: team work, communication, destroying the imbalance of power, narratives

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Knowing this is what was waiting for us outside, it could have been pretty hard to sit indoors all day... (Harbour of San Diego, view from the Convention Centre steps after my walk last night)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

Luckily it was highly engaging and much hope was offered (Bright Spots in #RightCare, highlighting innovative successes)

My actions as a result of today:

What was missing?

  1. Emphasis on relationships between patient and caregiver. The ONLY big mention about meaningful relationships was by a Reverend B. Stanfield during his reflection at the end; the data tell us that strong relationship = better care, and less costly care
  2. Focus on patient safety. Americans talk A LOT about cost! Cost is important, but were this conference anywhere else in the world, the main focus would be on reducing harms done to patients by too much or too little medicine.
  3. Acknowledgement of this as a world-wide cultural issue. There was a lot of discussion about insurance companies, ways of paying physicians, etc. as if these financial structure problems all explain the issue; some people seemed to believe that changing the way doctors are paid – abandoning fee-for service payments – would fix everything. But, there is no system of remuneration that incentivizes good care. "Wrong care" is a problem around the world, even in socially progressive and fully public health systems. 
     

I can't wait to see what is in store for us tomorrow!

The Upshot reflects: Patients overestimate benefit and underestimate harm of tests & treatments

In February, an excellent systematic review article appeared in JAMA as part of their "Less is More" series. Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review by Drs Tammy Hoffman and Chris Del Mar provides a comprehensive overview of patients views of the risks and harms of various tests, procedures, and treatments.

Their Conclusions and Relevance section explains the take-away it nicely:

The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.

This week, the NY Times Upshot - a source I'm finding myself reading more and more often - posted their reflection on the article, If Patients Only Knew How Often Treatments Could Harm Them. They beautifully wove together some of the data from the article to make it easier to digest and understand.

For example, they highlight the 2012 Annals of Family Medicine study that looks at patient estimates of the benefits of screening for bowel cancer. 

94% of patients overestimated the benefits of bowel cancer screening.

Simple and persuasive examples like that help explain the problem with our current care, and the article culminates in a summary written by Drs Frakt and Carroll that is completely in line with the principles that drive the Less is More in Medicine approach:

Many of the studies in the systematic review show that people report that they would opt for less care if they better understood benefits and harms. Improved communication could better serve patients and might improve the efficiency of our health system if patients focus on getting the types of care for which the benefit outweighs risk of harm.

Since they've done such a great job expounding the article, I feel no need to provide my own explanations or reflection.

 These kinds of articles come into my email and RSS reader and across my twitter landscape in droves; being overrun with articles and action in the field of overdiagnosis/testing/treatment is a delightful problem to have.

Source: http://www.nytimes.com/2015/03/03/upshot/i...

Can this app prevent Overtesting? A look at SnapDx

Sometimes, a new idea is exactly what we need to tackle a longstanding, otherwise insurmountable problem. A little bit of innovation can go a long way.

On the other hand, some new technologies are sexy and flashy but they don't really make a difference for society, or they generate new problems worse than the old.

I'm always on the lookout for creative solutions to the problem of overdiagnosis. Patients, healthcare providers, and society as a whole need to make changes to help create a sustainable, high-quality health care system.

In Doctors create app to help diagnose, treat patients at point of care, Globe and Mail journalist Ivor Tossel describes the aims behind SnapDx.

Dr. Rahul Mehta, an internal medicine resident at the University of Calgary, partnered with colleague Dr. Aravind Ganesh to create the SnapDx app. The app uses evidence-based guidelines to help guide physicians delivering care.

SnapDx Clinical is an efficient bedside assessment tool designed for use by medical trainees and clinicians at the point of care.

We provide the best evidence-based questions and tests to be used as part of your history and physical examination to confidently sort through your differential diagnosis. (from iTunes App description)

The idea is that SnapDx can help aid decisions about diagnosis, giving clinical probabilities that might override the need for ordering laboratory or radiological tests. It does this by emphasizing thorough physical exams, filtering these findings through well-evidenced decision-making tools, and providing probabilities for diagnosis.

Try downloading the SnapDx App (iTunes) yourself, or see the screenshots below for an idea of what it looks like.

I applaud the effort, and I imagine it must have taken a heroic effort to tackle the statistical nightmare behind the scenes, converting everything into a standardized interface.

Despite recognizing this, I must admit I found it a bit cumbersome and hard to understand. Each section has an estimated pre-test probability which is often set to the prevalence rate from a major research study; then, you tick yes/no to various scoring criteria (which are helpfully described in the Info sections). With this, you see the probability for/against a diagnosis. I think. Though it doesn't explicitly say if you should order a test, or which test you should order.

I got a bit bogged down in the details. One big issue I had is that I was not clear on is how to set the positive pre-test probability accurately.

 

For example: when I tried the Pulmonary Embolus (PE) tool, I was thinking of a patient who had recent surgery, recent cancer, immobilization, chest pain, tachypnea, no fever, a normal blood gas, and a normal chest x-ray. There was almost no other diagnosis possible besides a clot in his lungs. Yet because he did not have signs of DVT, hemoptysis, a clotting history, or tachycardia he would not score very high on any of the scales. Of course my pre-test probability for him was high, but I don't know if it was 50% or 99%, and the possible harms of a CT-scan were outweighed by the benefit of ensuring the treatment (high-dose blood thinner; possibly quite harmful) was in fact necessary.

The ambition of Drs Mehta and Ganesh is admirable, and I will keep the app around, looking for future iterations of it. It has the potential to improve clinical accuracy and to decrease ordering of tests that would only confirm what we already know from physical exam. 

Using our detective skills rather than requisitioning a test? It is a great idea.