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

Overdiagnosis and overtreatment carry a number of widespread consequences both at the patient level and at a national level.  Treadwell and McCartney do well to highlight some of the culprits of this unhealthy practice, with the dilemmas associated with following national guidelines being a main offender. To this day, we remain driven to sculpt patient care according to outcomes of clinical trials; the principle concern with this approach is that those formulating the trials and those who are required to deliver patient care have differing goals. This runs the risk of providing ineffective patient care.

Carrying out an audit recently against the NICE hypertension guidelines for investigating target organ damage highlighted the magnitude of the effects of impractical guidance.¹  A few patients in the sample were found to have an eGFR between 60-90ml/min/1.73m2. Therefore, do we label these patients as having chronic kidney disease stage 2?  If so, how would these patients feel being told that they had signs of kidney failure?  Furthermore, how much more differently would we be managing these patients if they had an eGFR above 90ml/min/1/.73m2?  The psycho-social implications of carrying out investigations are often neglected but it is important to consider what the outcome of investigations would mean to patients. Sometimes, I feel we need to take a step back and ask “why am I carrying out this investigation?” and “what is the likelihood that the outcome of this investigation will improve this patient’s wellbeing?”  These are just some of the questions that distinguish a doctor from a guideline-centred robot.

Reference

1.  National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management.  Published date: August 2011. www.nice.org.uk/guidance/cg127/chapter/1-Guidance#assessing-cardiovascular-risk-and-target-organ-damage (accessed 4 Apr 2016)