by Dr. Helmy Haja Mydin. First published in the New Straits Times 7 June 2014

MEDICAL TREATMENT: Screening all aspects of a patient is essential in making a proper diagnosis. One of the first lessons a medical student learns is the importance of taking a thorough history of the patient. My professors often stress that most diseases can be diagnosed with comprehensive history-taking, thorough clinical examination and a few basic medical tests.

This old adage in medicine has actually been proven — a study published in the journal Archives of Internal Medicine showed that combining history, physical and basic tests led to a correct diagnosis in three out of four patients, indicating that more sophisticated tests should not be done as a routine.

The increasingly ubiquitous use of modern technology in medicine is a double-edged sword.

While there is no denying that we have been able to diagnose and treat more diseases as a result of technological advancements, there is a downside to this ever-changing landscape — diagnostic tools can sometimes be too sensitive.
We increasingly identify “abnormalities” that were hitherto unknown or come across disease stages that are less severe and would not normally cause patients any harm if left untreated.

Overdiagnosis may also come in some forms of medical screening. For example, there is the assumption that a “wellness check” is useful even in a healthy individual.

Although there is no evidence to support this, some laboratories have been quick to seize this commercial opportunity by offering packages of blood tests that are marketed as “health screens”. Such screens can play a role but are misleading if not interpreted in context.

Another example is the use of tumour markers for screening. With a few notable exceptions, most tumour markers are worthless in identifying cancer. Cancer is far more likely to be picked up via thorough history-taking and clinical examination, followed by appropriate imaging.

The consequences can be dire. Individuals may be incorrectly labelled with disease, leading to an unending cycle of tests and unnecessary treatment.

This is especially true for those with false positive results i.e. given a positive diagnosis when none actually exist (it is worth remembering that no test is 100 per cent accurate).

False negatives are also dangerous. For example, the presence of HIV positivity is usually detected three months after contracting the virus.

Any test done before this period is thus falsely reassuring, especially if the results are not interpreted within a clinical context.

The consequences of overdiagnosis are not limited to the individual — society suffers as well.

The overuse of antibiotics and subsequent increase in antibiotic resistance has alarmed the World Health Organisation (WHO). Its assistant director-general for Health Security Keiji Fukuda recently said: “Without urgent action by stakeholders, the world is headed for a post-antibiotic era, in which common infections and minor injuries which have been treatable for decades can once again kill.”

Overdiagnosis also increases healthcare costs due to both excess investigations and the side effects of unnecessary intervention (it has been estimated that US$200 billion is wasted every year in the US alone).

These not only drive up the cost for the public sector but also the cost of insurance premiums, further decreasing affordability and access.

Patient anxiety and psychological distress increase as a result of health concerns as well as the mounting medical/health insurance bill.

Richard Hayward, a prominent neurosurgeon, coined the term Victim of Modern Imaging Technology (Vomit) to describe patients who fell into these categories. He also pointed out quite presciently that “the Internet is the most potent anxiety provoking system ever devised”.

The Internet is a reason that increasing numbers of individuals seek excess investigations. The democratisation of information has not developed in tandem with an increase in the ability to critically analyse all the data that is made available.

The propagation of false and misleading information in social media such as Facebook also increases levels of anxiety, alongside creating an exaggerated view of the capabilities of modern medicine.

Doctors also contribute to the overdiagnosis and subsequent overtreatment of patients. Some succumb to the pressure of needing to come up with a firm diagnosis, the fear of malpractice complaints or may just lack knowledge.

Some feel the need to be proactive rather than adopt a more conservative “watch and wait” approach, especially when faced with demanding patients who want to see “their money’s worth”. Others may be profit-driven as the current system financially rewards activities rather than outcomes.

The mainstay of intervention in such situations is education. The public should be made aware that investigations alone do not reveal the underlying health status of an individual – we should steer away from thinking that a doctor who orders more investigations is automatically a better one.

Some conditions, such as the common cold, should not be treated with antibiotics. Guidelines, written by those without conflicts of interests, should be disseminated to doctors and its adherence be used as a key performance indicator when analysing the performance of hospitals.

This should also form the basis of reforming payments schemes – hospitals should be rewarded for positive health outcomes and not on the basis of the number of interventions.

Private hospitals should also self-regulate in a proactive attempt to avoid possible government intervention. The freedom to pursue profit comes with a degree of responsibility and the lack of such responsibility will only act as a call for regulatory intervention that may serve political goals but not necessarily the patient.

A larger philosophical issue is also at play — the likes of smart phones and social media should be harnessed to help us function and not be tools dictating our lives. Similarly, technology should be utilised to optimise the management of diseases but is not an end in itself.

Hipprocrates, the father of medicine, wrote that all aspects of a patient — the symptoms, habits, sleep patterns, signs — are essential in making a diagnosis. It is telling that his observations are as true today as they were then.

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Dr. Helmy Haja Mydin is a founding associate of IDEAS

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