The Naked Doctor: profiling overdiagnosis and overtreatment. By Dr Justin Coleman
Naked Doctor aims to encourage discussion and awareness of the opportunities to do more for health by doing less. It is a compilation of articles, books and other works that highlight overdiagnosis and overtreatment.
It is a project of Dr Justin Coleman, a GP who works in Aboriginal and Torres Strait Islander health in Brisbane. He holds a Masters in Public Health, and is President of the Australasian Medical Writers Association. You can also find him on Twitter.
Launched in January 2012, Naked Doctor is a work in progress. Comments and suggestions are welcomed.
Below are two items: an introduction to the project; and Naked Doctor’s first entries (some articles are from subscriber-only journals; if you are unable to access an article, please leave your details on the bottom of this post or email Croakey asking for a copy).
Note: Naked Doctor was last updated on June 23, 2013 with this article at Croakey: An indepth look at the pitfalls of “cutting edge” medicine
Introducing the Naked Doctor: When is ‘no action’ the best action?
Justin Coleman writes:
The modern doctor seems to have an intervention for every occasion. He or she wears a magician’s coat of surprises, each more incredible than the last. Hidden pockets contain pills, scalpels and lasers, with sophisticated medical tests providing the performance instructions.
At its finest, the medical method is impeccable; type I diabetes was a rapid death sentence prior to insulin and accurate blood sugar tests. Sometimes, though, the heavy clothing creates it own problems. Tests point to the wrong diagnosis, treatments cause harm and the promised magic fails.
Some failures are a consequence of bad luck and random variation. But the closer we study these problem areas—applying the scientific method—the more we find predictable patterns emerging. Many tests and interventions fail because they should never have been used in the first place.
The Naked Doctor probes the places in medicine that would be better stripped bare. Places where the correct option is to do nothing. The ‘doctor’s bag’ accompanying a home visit before the second world war contained no medication which would be considered of any use today, and quite a few dangerous poisons. The physician would have been of more use turning up empty handed—or, given the lack of latex gloves and infection control, perhaps not turning up at all. The modern example of cancer screening via whole-body CT scanning offers as much protection as the emperor’s new clothes, and the guileless emperor would be better off naked.
Naked Doctor’s old anatomy professor Norm Eisenberg used to claim ‘only half of the stuff we teach you in this medical course is true. The problem is, we don’t know which half!’
Luckily, various health professionals and journalists around the globe dedicate themselves to steadily peeling back the covers. Naked Doctor exposes their disrobing of over investigation and overtreatment. We invite you to watch, and to contribute.
Naked Doctor: the list
Start at home with our very own Melissa Sweet who introduced the over-intervention theme to Crikey readers. A systematic approach is needed to balance the all-powerful “give us more” lobby.
Speaking of which, Melissa does give us more; in her non-Croakey spare time, she sums up our ‘less is more’ theme at Inside Story.
Recent Croakey stories include Simon Chapman refuting the claim of the UK quit smoking campaign that ‘not many’ smokers quit by going cold turkey, and Olga Anikeeva tries to stem the tide of antibiotic resistance.
Adelaide psychiatrist Jon Jureidini offers a fine explanation of ‘unexplanations’ in psychiatry. Jon moonlights as spokesman for Healthy Skepticism, a small group with a big mandate to counter misleading drug promotion.
Brisbane GP Andrew Gunn’s unravelling of the numbers needed to treat and to harm (NNT, NNH) is worth reading for the opening quote alone: “It is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.” Philippe Pinel 1745-1826. Oops, a spoiler! Read it instead for the Galen quote, which is even better.
Sharon Beglee at The Daily Beast pens a neat appraisal of situations where saying ‘No’ to a test or procedure can potentially save your life. Some thoughtful doctors are voting ‘No’ when it comes to their own health—and Sharon names names.
In 2010, Archives of Internal Medicine started a column ‘Less is More: How Less Health Care Can Result in Better Health’. Section editor Deborah Grady maintains the impressive article list. Naked Doctorrecommends a pleasurable browse through the less-is-more garden, plucking full-texts at whim. A commentary on the overuse of stents in stable coronary artery disease describes what went wrong in previous meta-analyses, which included acute-MI patients. Nothing wrong with the number crunching; the results just didn’t apply to most of the stent population. Overuse of health services is understudied; why has it taken decades to reduce antibiotics for viral infections, despite the education campaigns themselves almost going viral?
Josh Freeman, physician educator, Kansas US, writes a lovely blog mixing medicine with social justice. A number of articles discuss the inequities of spending money on treatments that don’t work. He worries about sounding nihilistic when identifying useless screening tests (know the feeling!) or when criticising doctors who don’t keep up with significant shifts in evidence. But that’s part of what we clinicians get paid for.
Shannon Brownlee discusses a study by cardiologists Grace Lin and Rita Redberg, who designed three theoretical cases where evidence suggests non-intervention was the correct treatment. They found that their cardiologist colleagues would almost always recommend surgical intervention. Surprise! Maybe author Upton Sinclair had it right when he said: It is difficult to get a man to understand something when his salary depends upon his not understanding it. Talking of which, it is a concern when the BMJ notes that, of the chairs and panel members producing North America’s screening and treating guidelines for hyperlipidaemia and diabetes, half have financial conflicts of interest.
Always worth a mouse click is Dr Richard Lehman’s journal review which consistently espouses the same themes as Naked Doctor but does it on a weekly basis and is wittier. Only click on him if you promise to return. The American health system is saturated with the influence of the pharmaceutical and medical devices industry: huge payments are made directly to individuals or institutions to influence purchasing decisions. In the UK, we call this corruption, but only for the time being.
We previously invited Dr Gary Schwitzer (HealthNewsReview.org) to come out of the closet and declare himself a Naked Doctor. Gary prefers to leave his hat on, but sent us a large series of articles on disease-mongering and on overtreatment. He recently highlighted 10 imbalanced TV news stories around health screening from the respected US ABC.
Chris Del Mar’s BMJ editorial provides a cogent argument for avoiding antibiotic prescription for colds, sore throats and ear infections. Unfortunately, patients expect doctors to intervene, and even when they don’t, doctors expect that their patients expect intervention. Confused? Paul Little explains the concept here.
Pharmed Out is a Georgetown University project educating healthcare professionals about pharmaceutical marketing practices. Check out the video links on the home page. A former drug rep ‘fesses up: Statistics are like prisoners—torture them enough and they’ll tell you what you want to hear! Grab a ‘No Drug Reps’ certificate for your waiting room or play Drug Ad Bingo in your spare time.
Departing boss of the US Medicare and Medicaid system, Dr Donald Berwick, lists ‘overtreatment’ as the first of five reasons for the very high 20-30 percent of US health spending he calls waste that yields no benefit to patients.
Has all this scepticism left you feeling naked? If so many treatments don’t seem to make much difference, what is left? It’s not our brief to list the many interventions that do work, but we do like Dr Mike Evan’s entertaining video which demonstrates how physical activity can be more effective than pharmaceuticals. The same observation prompted ‘exercise prescriptions’, championed by the folk at Exercise is Medicine, as an alternative clothing option for naked doctors.
Revealing what lies behind the screening
We live in testing times. The National Cancer Institute provides a wordy but interesting overview of the hazards of cancer screening.
H. Gilbert Welch, author of ‘Overdiagnosed’ (see books, below) is a natural wordsmith, crafting a fine article for the NYT: If you feel O.K., maybe you are O.K. The truth is, the fastest way to get…disease…is to be screened for it.
Two former ‘track favourites’ for cancer screening—mammograms and PSA tests —seem to be running off the pace in 2012, although both still have plenty of backing. The controversy provides insight into the pros and cons of screening tests.
Med Page Today is a hardworking site which covers medical news for clinicians and is prepared to call bad behaviour when spotted. Its scope is broad, so use the search function to find topics such as the risks of mammography or the increased likelihood of an ADHD diagnosis in kids who start school early. For those who can cope with long lists, read ’22 things amiss in medicine today’, by the formidable editor-at-large Dr George Lundberg, whose time at the helm of JAMA wore down his inclination to pull punches.
Patients referred for MRIs by physicians who owned their own MRI machine were almost twice as likely to have no pathology on review by an independent radiologist. Nothing beats the moolah as an incentive for ordering a test. Do private hospitals also see dollar signs when over treating patients with dementia?
Books that bare all
British epidemiologist Goldacre bases the book on his weekly ‘Bad Science’ column in the Guardian, where he gives bad medicine a lot of column inches. In the chapter ‘Pill solves complex social problem’, he even makes the big call, ‘Before 1935 doctors were basically useless.’ Older Naked Doctor readers excepted, of course.
How We Do Harm: A Doctor Breaks Ranks About Being Sick in America
Otis Brawley and Paul Goldberg
Dr Brawley, Chief Medical Officer with The American Cancer Society, closes ranks with everyone else in this blog as we all break ranks with those forces promoting ‘the overtreatment of the rich, the under treatment of the poor [and] the financial conflicts of interest that determine the care that physicians provide.’
The Treatment Trap: how the overuse of medical care is wrecking your health and what you can do to prevent it
Rosemary Gibson and Janardan Prasad Singh
For a taste of what lies behind the logorrhoeic title, Gibson blogs here. Her 16 years’ messing about in the politics of health quality and safety gives her a keen insight into the US health system
Overtreated: Why too much medicine is making us sicker and poorer
Shannon Brownlee, 2007, US
Find out about Roemer’s Law ‘A built hospital bed is a filled hospital bed.’ Discover the ‘Limits of Seeing’, where high tech scans make us as transparent as jellyfish, but just as often cloud the diagnosis. And read the last chapter ‘Less is More’, which would have made a great title for this Croakey page, if only Naked Doctor had thought of it first.
Testing Treatments: Better research for better healthcare
Imogen Evans, Hazel Thornton, Iain Chalmers, Paul Glasziou
With the addition of Queensland’s Paul Glasziou, this second edition discusses how to ensure research into medical treatments best meets the needs of patients. The chapter Earlier is not necessarily better covers a Naked Doctor pet theme of the benefits and harms of screening tests.
Overdiagnosed: Making people sick in the pursuit of health
H. Gilbert Welch, Lisa Schwartz and Steve Woloshin
As a society consumed by technological advances and scientific breakthroughs, we have narrowed the definition of normal and increasingly are turning more and more people into patients. Well worth a read: but why take Naked Doctor’s word for it, when you can read the BMJ book review by Croakey regular and fellow sceptic Ray Moynihan.
Ten questions you must ask your doctor
Ray Moynihan and Melissa Sweet
Ray and Melissa would make their mothers proud and their GP nervous. Their approach to keeping the bastards honest is patient-driven quality control at its best. I just hope they book longer consultations. There is little doubt that a dose of healthy scepticism is just what the doctor ordered. Indeed, the Naked Doctor orders scepticism twice daily, taken with a glass of water and a grain of salt.
House of God
Shem’s classic 1978 novel has the narrator as an intern admitting his hospital’s most important benefactor and secretly ordering no investigations or treatment. The patient’s rapid improvement underlines the thirteenth and final law taught to the intern by his wise mentor, the Fat Man: The delivery of good medical care is to do as much nothing as possible. Another Naked Doctor favourite is his tenth law; If you don’t take a temperature, you can’t find a fever. Indeed!
Disclaimer: Reading House of God as an intern was Naked Doctor’s original inspiration for a career-long interest in avoiding overtreatment. He does still own a thermometer and uses it discretionally.
Naked Doctor welcomes suggestions for inclusion on this list, but is responsible for the final decision about which entries are included.
To make suggestions or to join the discussion about this project, please visit this Croakey post.