Overdiagnosis in Medicine: Dr Justin Coleman
Today’s podcast features Australian GP, writer and thinker Dr Justin Coleman.
Justin is a GP currently working in Brisbane in Aboriginal Health at Inala Indigenous Health Service.
Justin is also a prolific writer – he has been producing great medical writing for about 20 years. He is the president of the Australian Medical Writer’s Association, a regular columnist at the Medical Observer and a blogger at drjustincoleman.
In the past he has been responsible for the GP Tips series which has run since 1998 and includes more than 650 ‘handy hints’ that you might find useful in your office practice – a truly wonderful resource.
Justin has more recently been writing a column at the Croakey blog entitled “The Naked Doctor” which looks at the modern medical phenomenon of overdiagnosis, over-treatment and unnecessary interventions. When I read his recent article on the “pitfalls of cutting edge medicine” it really struck a cord with me. So ever since then I have been wanting to have Justin on the podcast to share his insights.
I think we just really started to scratch the surface of this fascinating topic. I do hope he will come back soon and tell us more about some of the specific areas that we as doctors need to be better gatekeepers in the world of medical misadventure.
There are a few articles and papers discussed which are referenced below:
The BMJ series is called Too Much Medicine
The other big series of articles is called ‘Less is More’ at JAMA’s Archives of Internal Medicine
The BEACH data I mentioned is at: Bayram C, Britt H, Miller G, Valenti L 2009. Evidence-practice gap in GP pathology test ordering: a comparison of BEACH pathology data and recommended testing.
The testosterone article is from MJA 2012 “Testosterone Marketing Disease Mongering”
And one quick correction – Justin mentions the outgoing administrator of the USA Medicare boss’s comments on the huge waste in the American Health system. The chaps name is Dr Donald Berwick, and the article that Justin mentions is here in the New York Times.
Onto the Podcast DIRECT DOWNLOAD HERE Enjoy, Casey
Clinical Case 121: Supracondylar Sono Subtlety
Clinical Case 083: Itchy britches
Clinical Case 011: Psych Transfer in extremis
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Brilliant podcast, thanks!
As a medical educator, I spend a lot of time trying to convince just-out-hospital GP registrars that diagnostic uncertainty in general practice is not best handled by a rapid-fire machine-gun assault of indiscriminate tests. I explain that (with some notable exceptions), the best diagnostic tool we have is often follow up over time.
I’m interested to hear how other educators and supervisors help their learners become more comfortable in recognising when less is more.
Would love to hear more from Justin about widespread Vit D and testosterone testing and treatment – two of my personal bug bears.
Excellent show! It’s really interesting to hear overdiagnosis from an expert’s perspective since it’s becoming more common nowadays for doctors to diagnose excessively just to squeeze more money from their patients. Gonna share this with my doctor and see what he thinks. 🙂
Hi Mike
Thanks for your comment. I think you raise an important point that I would really like to clarify.
The podcast discusses overdiagnosis in medicine – however I really want to make this very clear – all doctors are guilty of this from time to time and it is not an intentional or malevolent act.
The idea that doctors “over diagnose”, “over treat” or “over investigate” in order to make a financial or other personal gain is a total falsehood and I really want to make it clear that neither Justin or myself believe that our colleagues make these decisions in bad faith. Quite the converse is true in fact – most overdiagnosis is the result of doctors attempting to do better by their patients and not “miss” important diagnoses.
The truth is that the characteristics of commonly used tests and treatments are complex and often poorly understood by the majority of practitioners. It would be a wonderful world if a positive test result ALWAYS meant a disease was present and treatment required, or that a negative test reassured that all was well – however that is not how it works. Medicine is an imperfect, messy and fundamentally human science. Doctors are in the unenviable position of making sense of the massive volumes of data that modern practice generates.
The pressure of the increasingly hostile medico-legal environment also tends to drive doctors to err on the side of “safety” in over-investigation which unfortunately can paradoxically result in more harm than benefit for well, low-risk patients. Also there is a lot of misinformation in the guise of education spread by companies with a vested interest in doctors testing or prescribing more – we are a cynical lot – but I am sure that on some level these strategies do result in an increase in our use of inappropriate tests – but this is certainly on a subconscious level. There is plenty of evidence that this type of advertising and persuasion works on doctors – but this is says more about us as humans, rather than suggest that we are corrupted by money to actively treat our patients differently.
So thanks for your comment. I hope that makes the issue you raised clear.
Casey
This is very interesting! This is the first time I heard about this doctor, and I believe I can learn a lot from his materials. I would definitely share this news to my doctor friends. Thanks for sharing this, you’ve been an eye-opener to me. Would love to hear more.
Beware of mimicking investigative patterns from a tertiary referral centre because:
1) Pre-test probability is higher (spectrum/referral/workup bias)
2) Cost effectiveness is in favour of aggressive investigation due to bed cost of inpatient stays
seems about right