Editorials Overdiagnosis and overtreatment: generalists — it’s time for a grassroots revolution

Ineffective and harmful medical practices treatment harms, from the mild to the fatal, to mention the opportunity cost created by have always been with us, but the scale and waste of resources is inevitable on a inevitable ‘consultation hijacking’. and institutionalisation of overdiagnosis and grand scale. The critical issue of opportunity This activity may feel sensible, but lacks overtreatment have expanded exponentially cost may be raised but disregarded in cost- evidence and distracts from the need in the last few decades. effectiveness decisions.4 for more challenging solutions such as Modern concern has been articulated None of this is simple; overdiagnosis addressing the obesogenic environment through worldwide movements such as and overtreatment arise as consequences or improving social care for people with the Preventing Overdiagnosis conferences, of activities that have a degree of benefit dementia. campaigns such as the BMJ’s ‘Too Much to some. Difficult questions arise about Medicine’, JAMA’s ‘Less is More’, Italy’s how harms and benefits are weighed or CHANGING THRESHOLDS AND ‘Slow Medicine’ movement, and the US perceived, and how to offer real choice INDICATION CREEP (now international) ‘Choosing Wisely’ to patients rather than simply what the Thresholds for labels such as pre- project. In 2014 the Royal College of contract or guidelines direct. diabetes or CKD are created based on General Practitioners (RCGP) established We believe that generalists have specific the identification of risk rising above the its Standing Group on Overdiagnosis expertise here. Drivers for clinical practice average, hence target populations move (Supporting Shared Decisions in Health tend to originate from specialist research. ever closer to containing half of older adults. Care). Specialists dealing with single conditions This tends to precede evidence of effect on Overdiagnosis has been defined simply may have disease-specific endpoints in endpoint outcomes for the new ‘patients’ at as ‘... when people without symptoms are mind, but these need to be prioritised by the mild end of the risk spectrum.9,10 diagnosed with a disease that ultimately the patient in the context of their wider Lower treatment thresholds always will not cause them symptoms or early health issues and perception of risk and create an increase in the number of death’ and is also used as an umbrella benefit. For the clinician, these endpoints patients taking medication for no benefit term to include ‘... the related problems need to be prioritised with the knowledge in order that a few might. Announcing its of overmedicalisation and subsequent of consequences of interventions on the most recent lipid guideline, the National overtreatment, diagnosis creep, shifting wider population or system. Generalists Institute for Health and Care Excellence thresholds and disease mongering’.1 Some are handed the responsibility of enacting (NICE) estimated that, if everyone eligible commentators use Too Much Medicine to population-level interventions to achieve took treatment, then we might prevent embrace such wider issues.2 specialist goals but we treat individuals who 28 000 heart attacks, 16 000 strokes, and Drivers of overdiagnosis are well may, rightly and entirely reasonably, take a 8000 deaths over 3 years. We would also described. Advancing technology allows different view. give statins to 4 448 000 patients for no detection of disease at earlier stages or benefit.11 ‘pre-disease’ states. Well-intentioned PSEUDO-SOLUTIONS TO DIFFICULT Wishing to reduce overdiagnosis and enthusiasm and vested interests combine PROBLEMS overtreatment does not imply therapeutic to lower treatment and intervention thresholds so that ever larger sections Public health problems without easy nihilism, nor a desire to abandon preventive of the asymptomatic population acquire solutions are fertile ground for large-scale medicine. Rather, it forces us to aim for an diagnoses, risk factors, or disease labels. over-activity in primary care. NHS Health understanding of the evidence base that This process is supported by medicolegal Checks were introduced nationally with a assists patients to make choices in a useful fear, and by payment and performance financial incentive as an apparent solution way, cognizant of benefits and harms. indicators that reward over-activity. It to metabolic disease, despite four decades GPs not only see the consequences has led to a guideline culture that has of evidence showing such programmes of overmedicalisation but also carry the unintentionally evolved to squeeze out do not affect population morbidity or extra workload caused by it. Iatrogenic 5–7 nuanced, person-centred decision making. mortality. multimorbidity creates a burden of complex Underlying all this are little challenged, Dementia screening was not and harmful polypharmacy for patients and deeply intuitive narratives around the recommended by the UK National their carers. Doctors with responsibility for supposed benefits of early detection and Screening Committee and carries one condition may not have the generalist, intervention that are difficult to unpick for significant risk of harm through potential holistic overview needed to help the patient professionals and public alike.1,3 false-positive diagnoses of dementia,8 not sort valuable interventions from low-value This leads to real harms. The psychological burden of acquiring a disease label may appear hard to quantify — partly because of under-research — “Iatrogenic multimorbidity creates a burden of complex for something like chronic kidney disease (CKD). However, it becomes more obvious and harmful polypharmacy for patients and their when considering a false-positive diagnosis carers.” of dementia or a screening overdiagnosis of breast cancer. Patients are exposed to

116 British Journal of General Practice, March 2016 ADDRESS FOR CORRESPONDENCE “… we hope that, by redistributing our time away Julian Treadwell GP, Hindon Surgery, High Street, Hindon, Wiltshire from low-value interventions and towards high- SP3 6DJ, UK. value interventions, we ourselves will enjoy more E-mail: [email protected] fulfilling work, sharing decisions with our patients and reclaiming our role as expert generalists.”

ones. Defending our patients from the specialist and public health ideas needs to harms of Too Much Medicine needs to be updated. To do this we need a stronger happen not just in the consulting room, but part in the creative process of evidence REFERENCES also at local and national policymaking level. synthesis and policymaking. We need to 1. Moynihan R, Glasziou P, Woloshin S, et The RCGP has many potential ensure the ‘common voice’ is represented. al. Winding back the harms of too much mechanisms at its disposal, including We call on the makers of guidelines to medicine. BMJ 2013; 346: f1271. the development of evidence resources ensure that grassroots GPs, with such a 2. Carter SM, Rogers W, Heath I, et al. The challenge of overdiagnosis begins with its and priming our existing relationships valuable, broad perspective, are enabled to definition. BMJ 2015; 350: h869. with specialist colleagues and external have a greater influence in their production. 3. Heath I. Overdiagnosis:when good intentions bodies. In 2015 the RCGP Council passed ‘Ordinary’ GPs are valuable GPs, and we meet vested interests — an essay. BMJ 2013; a policy paper on overdiagnosis12 with call on those who might think that their 347: f6361. a recommendation for five ‘tests’ to be voice is not important to get involved in 4. National Institute for Health and Care applied to College output to reduce the risk shaping the future of our clinical practice Excellence. Costing report: lipid modification. of overmedicalisation: for our patients and for ourselves. Implementing the NICE guideline on lipid modification (CG181). July 2014. https://www.nice.org.uk/guidance/cg181/ • present evidence in a way that allows Julian Treadwell, resources/lipid-modification-update-costing- shared decision making and patient GP, Hindon Surgery, Wiltshire; Vice-Chair, RCGP report-243777565 (accessed 1 Feb 2016). Standing Group on Overdiagnosis; Editorial Board 5. Krogsbøll T, Jørgensen K, Grønhøj Larsen C, involvement (absolute risk, numbers Member, Drugs and Therapeutics Bulletin; GP Gøtzsche PC. General health checks in adults needed to treat); Appraiser, NHSE South Central. for reducing morbidity and mortality from • clarity about which populations evidence disease. Cochrane Database Syst Rev 2012; can reasonably be applied to; Margaret McCartney, 10: CD009009. • openness about uncertainty of the GP, Fulton Street Medical Centre, Glasgow; Chair, 6. Jørgensen T, Jacobsen RK, Toft U, et al. RCGP Standing Group on Overdiagnosis. Effect of screening and lifestyle counselling evidence; on incidence of ischaemic heart disease in general population: Inter99 randomised trial. • stating whether proposals for screening Provenance BMJ 2014; 348: g3617. have been approved by the National Commissioned; not externally peer reviewed. Screening Committee; and 7. Capewell S, McCartney M, Holland W. Invited debate: NHS Health Checks — a naked • finally, that declarations of interests be DOI: 10.3399/bjgp16X683881 emperor? J Public Health 2015; 37(2): 187– made public. 192. However, the most valuable resource is 8. The UK National Screening Committee. The UK NSC recommendation on Screening our time, and we hope that, by redistributing for Dementia. 2015. http://legacy.screening. our time away from low-value interventions nhs.uk/dementia (accessed 5 Feb 2016). and towards high-value interventions, we 9. Yudkin JS, Montori VM. The epidemic of pre- ourselves will enjoy more fulfilling work, diabetes: the medicine and the politics. BMJ sharing decisions with our patients and 2014; 349: g4485. reclaiming our role as expert generalists. 10. Moynihan R, Glassock R, Doust J. Chronic To this end, we should be clear about kidney disease controversy: how expanding definitions are unnecessarily labelling many opportunity costs. Every new innovation people as diseased. BMJ 2013; 347: f4298. or intervention that is suggested for GPs 11. National Institute for Health and Care should be accompanied by opportunity Excellence. Wider use of statins could cut costing and, unless there is new resource, deaths from heart disease. 2014. https:// current tasks should be identified to be www.nice.org.uk/news/article/wider-use-of- stopped in order to fit new work in. This may statins-could-cut-deaths-from-heart-disease (accessed 5 Feb 2016). require a more assertive generalism than 12. Royal College of General Practitioners. RCGP perhaps we are used to. We need to stand Standing Group on Overdiagnosis. For shared up and shape the clinical agenda from decisions in healthcare. http://www.rcgp.org. our unique perspective, drawing on the uk/policy/rcgp-policy-areas/~/media/Files/ work and resources of academic primary Policy/A-Z-policy/2015/C72 Standing Group on Over-diagnosis - revise 2.ashx (accessed 5 care and the evidence-based medicine Feb 2016). world. Our role as passive enactors of

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