BMJ 2015;350:h1095 doi: 10.1136/bmj.h1095 (Published 3 March 2015)
Page 1 of 2
Observations
OBSERVATIONS OVERDIAGNOSIS
Too much medicine is not just a problem of rich countries South Asia needs better recognition of the manifestations and drivers of overdiagnosis Anita Jain assistant editor, The BMJ, India One memory of medical school stays with me. It was our first day in clinical medicine, and we would be meeting a widely respected and feared professor. “Why have you taken up medicine?” he asked each one of us. Idealistic aspirations of serving the society and making a difference to the world came up.
“A barber does greater service to society than you ever will as a doctor,” he said emphatically. “You are here to make money.” I found this reality difficult to accept then, but his words ring true as I observe medical practice today. Last year the personal account of an Australian physician volunteering in India blew the lid off the practice whereby doctors receive a commission of 10-30% for referrals to diagnostic centres and to specialists.1 Doctors refer to this “cut practice” as essential to set up shop and run their business, but it has led to rampant abuse of investigations and unnecessary procedures. What makes the situation more deplorable is that patients largely pay for healthcare from their own pockets, and the increased costs are borne by them. Once regarded as the health “service,” healthcare is increasingly referred to as an industry. Driven by greed and devoid of regulation, medicine has become ever more commercialised. Doctors need to make a living of course, and to live well at that. Yet, for monetary incentives to drive clinical decisions is a problem.
The diagnosis imperative
Monetary incentives are not the sole driver of overdiagnosis, however. At a recent workshop,2 young doctors identified how throughout medical training they were taught, almost compelled, to reach “a diagnosis” and to offer several provisional diagnoses to be confirmed through a battery of investigations. Clinching a diagnosis got you acknowledgment from professors and peers and helped you crack the exams, sending a signal that a good clinician was one who could diagnose with precision. This reflects a disconnection from actual practice, where uncertainty is the norm. Often indeed, reaching a diagnosis might not align with patients’ needs, expectations, and circumstances. This culture of investigative medicine has boosted the growth of diagnostic services, the fastest growing segment of India’s
healthcare industry.3 The rise is propelled mainly by an increase in screening and follow-up tests for chronic diseases and cancers.4 Although the drivers of overdiagnosis in south Asia’s urban and affluent populations possibly mirror those in developed economies, overdiagnosis also manifests itself in care provided to poor and underserved segments of society, paradoxically sometimes because of lack of access to good quality diagnostic tests. Malaria presents one such challenge. Research from Asian and African countries where malaria is endemic shows that doctors tend to start presumptive treatment for malaria in patients with fever, even if laboratory test results are negative, resulting in overtreatment.5 6 7 The decision to treat is influenced by very real considerations of poor standards of laboratory reporting and the likelihood that patients may not follow up at the clinic if symptoms worsen. Overprescription of antimalarials has led to drug resistance and also missed treatment for serious non-malarial infections.
Local context A unique dimension of overdiagnosis in low and middle income countries is presented by extrapolation to the local context of guidelines derived from research in high income countries. For example, in a problem described as an “Asian enigma,” countries in this region continue to have a high prevalence of child malnutrition despite rapid economic growth and intensive efforts at the population level to boost nutrition.8 This sparked a debate recently. Arvind Panagariya, a professor of economics at Columbia University, attributes the overdiagnosis of malnutrition to flawed World Health Organization measurement standards for height and weight. Definitions of normal height and weight that are based on norms for rich countries may not work well when translated to an Asian setting, with its different genetic, environmental, cultural, and geographical factors.9 The food industry is meanwhile opportunistically spreading its tentacles in these large markets to promote their biscuits and snacks through government run nutrition supplementation programmes.10
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1095 doi: 10.1136/bmj.h1095 (Published 3 March 2015)
Page 2 of 2
OBSERVATIONS
The way forward Greater recognition of the various manifestations and drivers of overdiagnosis in this region is needed. It is heartening to see initiatives to pull back from growing reliance on a technology intensive clinical approach. Physicians in South Korea led a public campaign on the issue of overdiagnosis of thyroid cancer. Under the government sponsored national screening programme, diagnosis of various cancers, in particular thyroid cancer, has increased dramatically, making it the most common cancer. Mortality from thyroid cancer has remained steady, yet virtually all people with this diagnosis are treated. The physicians’ campaign resulted in the National Cancer Centre recommending against routine thyroid cancer screening in asymptomatic people.11 Similarly a group of cardiologists in India has set up the Society for Less Investigative Medicine to identify and cut back on unnecessary investigations.12
There is a need to engage with patients too, and tackle their fears and beliefs in demanding investigations and treatment that may not be necessary. Patient volumes in Asian countries mean markedly shortened consultation time to allow this. But for conscientious doctors there is no substitute for patient engagement. Steps are under way in India to curtail the practice of kickbacks for referrals and to set minimum standards of care and fixed costs for investigations.13 Sustainable change will require the medical community to recognise the far reaching consequences of their choices and actions. Doctors must take up the cause themselves. Remembering the ideals with which they took up medicine as their calling might help.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: None. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6
7 8 9 10 11 12 13
Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014;348:g3169. Jain A. Overdiagnosis: when is it too much care? BMJ blog 21 Oct 2014. http://blogs.bmj. com/bmj/2014/10/21/anita-jain-overdiagnosis-when-is-it-too-much-care. India Brand Equity Foundation. Sectoral report on healthcare industry in India. Oct 2014. www.ibef.org/industry/healthcare-india.aspx. KPMG, Confederation of Indian Industry. Excellence in diagnostic care: Creating a value chain to deliver an excellent customer experience. www.kpmg.com/IN/en/ IssuesAndInsights/ThoughtLeadership/Excellence_in_Diagnostic_Care.pdf. Leslie T, Mikhail A, Mayan I, Anwar M, Bakhtash S, Nader M, et al. Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study. BMJ 2012;345:e4389. Ansah EK, Narh-Bana S, Epokor M, Akanpigbiam S, Quartey AA, Gyapong J, et al. Rapid testing for malaria in settings where microscopy is available and peripheral clinics where only presumptive treatment is available: a randomised controlled trial in Ghana. BMJ 2010;340:c930. Reyburn H, Mbatia R, Drakeley C, Carneiro I, Mwakasungula E, Mwerinde O, et al. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 2004;329:1212. Ramalingaswami V, Jonsson U, Rohde J. Commentary: the Asian enigma. Unicef. www. unicef.org/pon96/nuenigma.htm. Panagariya A. Does India really suffer from worse child malnutrition than sub-Saharan Africa? Economic & Political Weekly 4 May 2013. www.epw.in/special-articles/does-indiareally-suffer-worse-child-malnutrition-sub-saharan-africa.html. Jishnu L. Tiger takes the biscuit. 31 Jan 2012. www.downtoearth.org.in/content/tigertakes-biscuit. Hyeong Sik A, Hyun Jung K, Welch HG. Korea’s thyroid-cancer “epidemic”: screening and overdiagnosis. N Engl J Med 2014;371:1765-7. Travasso C. Indian cardiologists plan campaign to reduce unnecessary investigations. BMJ 2014;349:g4740. Nandraj S. Private healthcare providers in India are above the law, leaving patients without protection. BMJ 2015;350:h675.
Cite this as: BMJ 2015;350:h1095 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Observations
OBSERVATIONS OVERDIAGNOSIS
Too much medicine is not just a problem of rich countries South Asia needs better recognition of the manifestations and drivers of overdiagnosis Anita Jain assistant editor, The BMJ, India One memory of medical school stays with me. It was our first day in clinical medicine, and we would be meeting a widely respected and feared professor. “Why have you taken up medicine?” he asked each one of us. Idealistic aspirations of serving the society and making a difference to the world came up.
“A barber does greater service to society than you ever will as a doctor,” he said emphatically. “You are here to make money.” I found this reality difficult to accept then, but his words ring true as I observe medical practice today. Last year the personal account of an Australian physician volunteering in India blew the lid off the practice whereby doctors receive a commission of 10-30% for referrals to diagnostic centres and to specialists.1 Doctors refer to this “cut practice” as essential to set up shop and run their business, but it has led to rampant abuse of investigations and unnecessary procedures. What makes the situation more deplorable is that patients largely pay for healthcare from their own pockets, and the increased costs are borne by them. Once regarded as the health “service,” healthcare is increasingly referred to as an industry. Driven by greed and devoid of regulation, medicine has become ever more commercialised. Doctors need to make a living of course, and to live well at that. Yet, for monetary incentives to drive clinical decisions is a problem.
The diagnosis imperative
Monetary incentives are not the sole driver of overdiagnosis, however. At a recent workshop,2 young doctors identified how throughout medical training they were taught, almost compelled, to reach “a diagnosis” and to offer several provisional diagnoses to be confirmed through a battery of investigations. Clinching a diagnosis got you acknowledgment from professors and peers and helped you crack the exams, sending a signal that a good clinician was one who could diagnose with precision. This reflects a disconnection from actual practice, where uncertainty is the norm. Often indeed, reaching a diagnosis might not align with patients’ needs, expectations, and circumstances. This culture of investigative medicine has boosted the growth of diagnostic services, the fastest growing segment of India’s
healthcare industry.3 The rise is propelled mainly by an increase in screening and follow-up tests for chronic diseases and cancers.4 Although the drivers of overdiagnosis in south Asia’s urban and affluent populations possibly mirror those in developed economies, overdiagnosis also manifests itself in care provided to poor and underserved segments of society, paradoxically sometimes because of lack of access to good quality diagnostic tests. Malaria presents one such challenge. Research from Asian and African countries where malaria is endemic shows that doctors tend to start presumptive treatment for malaria in patients with fever, even if laboratory test results are negative, resulting in overtreatment.5 6 7 The decision to treat is influenced by very real considerations of poor standards of laboratory reporting and the likelihood that patients may not follow up at the clinic if symptoms worsen. Overprescription of antimalarials has led to drug resistance and also missed treatment for serious non-malarial infections.
Local context A unique dimension of overdiagnosis in low and middle income countries is presented by extrapolation to the local context of guidelines derived from research in high income countries. For example, in a problem described as an “Asian enigma,” countries in this region continue to have a high prevalence of child malnutrition despite rapid economic growth and intensive efforts at the population level to boost nutrition.8 This sparked a debate recently. Arvind Panagariya, a professor of economics at Columbia University, attributes the overdiagnosis of malnutrition to flawed World Health Organization measurement standards for height and weight. Definitions of normal height and weight that are based on norms for rich countries may not work well when translated to an Asian setting, with its different genetic, environmental, cultural, and geographical factors.9 The food industry is meanwhile opportunistically spreading its tentacles in these large markets to promote their biscuits and snacks through government run nutrition supplementation programmes.10
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1095 doi: 10.1136/bmj.h1095 (Published 3 March 2015)
Page 2 of 2
OBSERVATIONS
The way forward Greater recognition of the various manifestations and drivers of overdiagnosis in this region is needed. It is heartening to see initiatives to pull back from growing reliance on a technology intensive clinical approach. Physicians in South Korea led a public campaign on the issue of overdiagnosis of thyroid cancer. Under the government sponsored national screening programme, diagnosis of various cancers, in particular thyroid cancer, has increased dramatically, making it the most common cancer. Mortality from thyroid cancer has remained steady, yet virtually all people with this diagnosis are treated. The physicians’ campaign resulted in the National Cancer Centre recommending against routine thyroid cancer screening in asymptomatic people.11 Similarly a group of cardiologists in India has set up the Society for Less Investigative Medicine to identify and cut back on unnecessary investigations.12
There is a need to engage with patients too, and tackle their fears and beliefs in demanding investigations and treatment that may not be necessary. Patient volumes in Asian countries mean markedly shortened consultation time to allow this. But for conscientious doctors there is no substitute for patient engagement. Steps are under way in India to curtail the practice of kickbacks for referrals and to set minimum standards of care and fixed costs for investigations.13 Sustainable change will require the medical community to recognise the far reaching consequences of their choices and actions. Doctors must take up the cause themselves. Remembering the ideals with which they took up medicine as their calling might help.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: None. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4 5 6
7 8 9 10 11 12 13
Berger D. Corruption ruins the doctor-patient relationship in India. BMJ 2014;348:g3169. Jain A. Overdiagnosis: when is it too much care? BMJ blog 21 Oct 2014. http://blogs.bmj. com/bmj/2014/10/21/anita-jain-overdiagnosis-when-is-it-too-much-care. India Brand Equity Foundation. Sectoral report on healthcare industry in India. Oct 2014. www.ibef.org/industry/healthcare-india.aspx. KPMG, Confederation of Indian Industry. Excellence in diagnostic care: Creating a value chain to deliver an excellent customer experience. www.kpmg.com/IN/en/ IssuesAndInsights/ThoughtLeadership/Excellence_in_Diagnostic_Care.pdf. Leslie T, Mikhail A, Mayan I, Anwar M, Bakhtash S, Nader M, et al. Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study. BMJ 2012;345:e4389. Ansah EK, Narh-Bana S, Epokor M, Akanpigbiam S, Quartey AA, Gyapong J, et al. Rapid testing for malaria in settings where microscopy is available and peripheral clinics where only presumptive treatment is available: a randomised controlled trial in Ghana. BMJ 2010;340:c930. Reyburn H, Mbatia R, Drakeley C, Carneiro I, Mwakasungula E, Mwerinde O, et al. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ 2004;329:1212. Ramalingaswami V, Jonsson U, Rohde J. Commentary: the Asian enigma. Unicef. www. unicef.org/pon96/nuenigma.htm. Panagariya A. Does India really suffer from worse child malnutrition than sub-Saharan Africa? Economic & Political Weekly 4 May 2013. www.epw.in/special-articles/does-indiareally-suffer-worse-child-malnutrition-sub-saharan-africa.html. Jishnu L. Tiger takes the biscuit. 31 Jan 2012. www.downtoearth.org.in/content/tigertakes-biscuit. Hyeong Sik A, Hyun Jung K, Welch HG. Korea’s thyroid-cancer “epidemic”: screening and overdiagnosis. N Engl J Med 2014;371:1765-7. Travasso C. Indian cardiologists plan campaign to reduce unnecessary investigations. BMJ 2014;349:g4740. Nandraj S. Private healthcare providers in India are above the law, leaving patients without protection. BMJ 2015;350:h675.
Cite this as: BMJ 2015;350:h1095 © BMJ Publishing Group Ltd 2015
Subscribe: http://www.bmj.com/subscribe
