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...

Why Survival Rate Is Not the Best Way to Judge Cancer Spending

The New York Times has a great piece on their Upshot blog about assessing value when it comes to testing and treating cancer. It can be very challenging to measure whether the money we spend on health care is providing good return, making a meaningful improvement for patients.

We want every dollar we spend to help people live longer and higher-quality lives. However, when data of survival rate is examined, it may lead to inaccurate conclusions about the effectiveness and worth of a test or treatment.

The Upshot expands upon Why Survival Rate Is Not the Best Way to Judge Cancer Spending. Dr Carroll explains how statistics - particularly the parameter of 'survival rates' - can mislead us into thinking we are helping patients, but because of lead-time bias and overdiagnosis bias, what we are measuring as "success" is not actually translating into improvement for the patient. Our mis-guided spending is leading to the point where we do not have money to spend on more impactful interventions. 

Read the article for clear explanations of these biases with illustrative examples, and consider that by focussing on the wrong measures, "we may be getting far less for our money then we think."

Source: http://www.nytimes.com/2015/04/14/upshot/w...

Coccidiomycosis and other "Zebras" in Medicine; reconciling with Less is More

This is the first time I've had a peer-reviewed article published. Shortly after I wrote an email to the patient, the subject of this case report, to let him know, I was looking through my other emails and realized not only was it published, but that it had become the cover story for this of the British Columbia Medical Journal (BCMJ)!

Read the article here: A textbook case of coccidiomycosis (web version or a PDF version).

Ok, perhaps I shouldn't be so proud as it's not the Lancet or BMJ, but I think the BCMJ is pretty darn good and it was exciting for me to get to share this case in so doing, to make good on a promise to this patient to educate others about his diagnosis. It was also great to work with a friend, the very smart Dr Barlow!

I also liked the reflective exercise of thinking about how a "Less is More" kind of doctor could still diagnose exotic conditions.


The article is about an uncommon fungus (coccidiomycosis) that a patient I saw in on Vancouver Island had acquired. There's an expression in medicine:

"When you hear hoof-beats, think horses, not zebras."


One should never jump to the exotic diagnosis. However,  occasionally, people do have exotic diagnoses.

Even though I had to order some specialized tests to find out for sure what he had, this practice is still consistent with the "Less is More" philosophy. The idea is that in avoiding all the unnecessary stuff, we can use our time and resources wisely to order the RIGHT tests and treatments. It also helps immensely when patients are aware of their own health and can tell us their story clearly.

It all worked out because we had:

- A clear patient, advocating for himself, open-minded & contributing to my assessment and plan
- A doctor with time to hear the patient's story, medical knowledge appropriate for the situation
- Judicious ordering of tests (wrong test for most people, the RIGHT test for him)
- Confirmation of a suspicion gained from the history and reviewing the labs/xray that were already available

This was a highly satisfying case. I'm rarely clever, and rarely have a patient who is as good a historian as he. It's a wonderful illustration of a working acute care system, the benefits of being a patient who takes ownership for his health, and that some obscure knowledge is tucked away in my brain which will sometimes emerge when needed!