THESIS: Preventing Overdiagnosis, the Quaternary Prevention

Maria Llargués Pou, a soon-to-be Family Physician in Barcelona, recently shared with me her Bachelor's Thesis. 

Her work - "Primum non nocere" Preventing Overdiagnosis, the Quaternary Prevention provides a concise introduction to the efforts around the world to prevent overuse of tests, treatments, and disease-labels, as well as the reasons we must address this growing issue.


Medicine’s much hailed ability to help the sick is fast being challenged by its propensity to harm the healthy 

Llargués Pou has beautifully laid out an evolution of ideas, from Ivan Illich's idea of Iatrogenesis, to Jamoulle's attempts to thwart iatrogenic harm with a public health model of Quaternary Prevention, and now, contemporary efforts to tackle overdiagnosis, like the Choosing Wisely Campaign and Preventing Overdiagnosis conference. Her paper serves as a great "backgrounder" for those who wish to learn more about the broad themes and history of this movement.

You can view the full text HERE.

Doctor, Shut Up and Listen (NY Times)

You've heard it 100 times, but perhaps this time it will sink in.

There's really no substitute for taking a thorough history of a patient and then supplementing it with a targeted physical exam, before considering any tests or interventions.

I'll admit, sometime I scrimp on the history (see below). I hate doing this because there's GOLD in the patient's words. You kind find out who they are, what is bothering them most, what they think is going on, and what you ought to do about it.

This is free, grade A info, and the only cost is time; filtered through a fancy medical education, what the patient says will guide everything. 

In the article Nirmal Joshi highlights the horrific results of crappy encounters:

Brief, rushed physician encounters were common, with limited opportunity for questions. A lack of empathy was often apparent: In one instance, after a tearful patient had related the recent death of a loved one, the physician’s next sentence was: “How is your abdominal pain?”

This past week, we were in the throws of influenza at our hospital. We still are. It was also the holidays and without the regular compliment of physicians, let alone Social Work, Occupational Therapy (OT), Physiotherapy(PT), Patient-Care Coordinators (PCCs), Speech Language Pathologists (SLPs), porters, Radiology Technicians, Phlebotomists, Pharmacists, etc. things basically ground to a halt. 

A lack of personnel and resources, combined with high numbers of new admissions, meant that everyone on my team was covering more than the usual number patients of varying acuity. And this, without the benefit of the usual allied professional help and expertise that we are dependent on working with to deliver high-quality care. So, time was limited. Simple questions to patients would be asked wherever possible, but I would never have left the building if I was being as thorough as I usually am. 

On the day where I started with a ward emergency (patients O2 Sats were 64%), I didn't eat lunch or take a bathroom break, another patient had new neurological symptoms and needed STAT imaging (and I got the radiologist to authorize it, but it still took 6 hours), a few other SNAFUs, and I stayed much later than usual, I simply could not find the time to practice a good 'ole H&P on every patient who warranted it. And I was very hungry!

I remember one patient with a complex story who was in for reason X but also happened to have problem Y (which was improving with treatment, but was initially life-threatening). The focus was on stabilizing the problem, which was actually going well. I expected the problems were related, and I could figure this out with a simple urine test. I did take the time to ask the patient about health problems, changes in medication, and to review the notes from specialists over the past year. But, with my phone ringing off the hook and patients needing to be seen, I didn't take the time to ask about some simple symptoms that might have helped steer the boat and figure out why Y had happened in the first place. I just ordered a lab test.

This is not something to be proud of, but I can certainly see how "Less is More" is sometimes easier said than done. I'm glad I'm conscious of the right way to do things but it is hard to always do that. Trying to find a balance between the mixed messages of "physician wellness is important" and "do everything beyond humanly possible to help people" makes it hard to end the day on a good note. 

I wish the system was structured in a way that the time and other pressures facing us didn't create situations where we have to choose between keeping sane (eg. taking a break) AND doing the right thing.

I'm nowhere near perfect but I really do enjoy getting to know my patients and playing "detective" to try to diagnose and treat their issues.

A lot of days, I miss my lunch.


Read the NY Times article HERE.