Dear Rodrigo

Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. Overdiagnosis is a side effect of testing for early forms of disease which may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. A typical example is a back pain.

Back pain is the largest cause of disability in the United States for working-age consumers and the second largest cause of physician office visits. The general category of low back pain is a complex mishmash of various conditions that produce pain in the back and/or radiating into the legs. When a patient presents at a primary care office with a new complaint of pure back pain, the prognosis for a quick recovery is good. The primary indicators of potential chronicity causing extended disability are psychosocial rather than physical signs. These low-risk patients are easily identified in a brief physician visit.

Clinicians who consult with these patients have an obligation to educate and support patients without increasing their concerns. Although additional diagnostic tests such as MRI appear to be harmless, in fact the discussion of normal aging signs often raises concerns rather than reassures patients. Any discussion of back injury with these patients is inappropriate because in most cases, back pain cannot be attributed to a specific event, but is more likely a hereditary factor.

If the patient prognosis can be modified by the physician for better or worse, what should they say to alleviate concerns without appearing to minimize the patient’s complaint?

Its necessary present to the patient the scientific evidence that back pain often has a favorable prognosis without diagnostic tests or therapy. Discuss with back pain patients that they can maximize their chances of quick, recovery. With these measures the cost decreases in attendance this pathology overdiagnosed.

Our biggest problem is that we don't have enough time to explain all this to patient

Years ago, I had a student (certified nurse studying healthcare management) doing a thesis on NANDA diagnoses in nursing. She presented video-taped anamnestic examinations to experienced teaching nurses and compared their ratings to those of nurses at the beginning of their carreer.

Experienced nurses focused on those aspects requiring support and immediate interventions, while beginners were more interested to do a complete examination and not to omit any diagnosis. => She interpreted this use of the NANDA catalogue as a kind of "overdiagnosis caused by self-defense".

Here is a reference, where she presented her thesis to a scientific meeting: Irrasch B., Frick U. (2007) Sind Pflegediagnosen ein Qualitätsmerkmal? – Eine Untersuchung zur Zuverlässigkeit von NANDA -Pflegediagnosen. 4. Internationaler Kongress für angewandte Pflegeforschung, Universität Witten-Herdecke, Witten (D), 11.-13. Oktober

Thank you for your answer. I never thought that this phenomenon could happen in this scenario!

I think it happens with medics too, especially those unexposed to emergency work. The also underdiagnise from pure clinical inexperience, and over investigate with imaging especially abdominal conditions.

I work on overdiagnosis in surgical pathology as a result of breast screening.

Dear Rodrigo

Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. Overdiagnosis is a side effect of testing for early forms of disease which may turn people into patients unnecessarily and may lead to treatments that do no good and perhaps do harm. A typical example is a back pain.

Back pain is the largest cause of disability in the United States for working-age consumers and the second largest cause of physician office visits. The general category of low back pain is a complex mishmash of various conditions that produce pain in the back and/or radiating into the legs. When a patient presents at a primary care office with a new complaint of pure back pain, the prognosis for a quick recovery is good. The primary indicators of potential chronicity causing extended disability are psychosocial rather than physical signs. These low-risk patients are easily identified in a brief physician visit.

Clinicians who consult with these patients have an obligation to educate and support patients without increasing their concerns. Although additional diagnostic tests such as MRI appear to be harmless, in fact the discussion of normal aging signs often raises concerns rather than reassures patients. Any discussion of back injury with these patients is inappropriate because in most cases, back pain cannot be attributed to a specific event, but is more likely a hereditary factor.

If the patient prognosis can be modified by the physician for better or worse, what should they say to alleviate concerns without appearing to minimize the patient’s complaint?

Its necessary present to the patient the scientific evidence that back pain often has a favorable prognosis without diagnostic tests or therapy. Discuss with back pain patients that they can maximize their chances of quick, recovery. With these measures the cost decreases in attendance this pathology overdiagnosed.

Our biggest problem is that we don't have enough time to explain all this to patient

In the interest of time constraints at the emergency room I do agree that emergency Dr. needs to make a quick decision regarding the patient's diagnosis and management ,But the time constraints at the emergency room should not be a barrier in going through a patient carefully in view of diagnosis and treatment.that helps even to prevent unnecessary admissions.Time that you spend on a patient depends on the complexity of the problem,chronicity and severity of the problem and it is tailor made on each patient. On the other hand careful examination of one patient should not compromise attending to other patients.

In community primary care (here in Australia: general practice), junior staff feel they "mustn't miss anything", often feel unable to tolerate ambiguity (which may be resolved with time), and feel they must be seen to be managing something that may be self-limiting. Their lack of confidence in their clinical judgement pushes them to investigate more. This is often at the expense of a more careful, thoughtful and detailed history and examination.

Senior staff may also feel time pressure, as outlined in others' answers.

However - our response should be to manage workforce appropriately, not increase unnecessary investigation.

I thank you all for your coments. I work at an academic secondary care hospital and would like to study overdiagnosis in various sectors of hospital activity as well as at primary care. Back pain, as Dr. Elias pointed out, is one of the most interesting things to study, particularly at the emergency rooms in brazilian hospitals. Also the question of overdiagnosis related to lack of confidence and intolerance to uncertainty of junior staff not only at primary care but also at emergency rooms, as Dr Bandler commented. I wonder if any of you have studied these issues in a more systematic way at your own practices or services.

Thank you

And your response makes me thing that I haven't expressed this accurately. It's not simply about "workforce" - but specifically about

a) supervision, its quality, its engagement and its proximity (we are now moving to off-site supervision particularly in some rural settings), - for junior doctors; and

b) hours worked, and income earned in those hours - for senior doctors.

I think the drivers of over diagnosis in ED setting are multiple.

1) medico-legal fear of missing a diagnosis being stronger than fear of over-diagnosis, especially when over-diagnosis usually leads to passing the problem on to a specialist of some sort. This can be framed as the medico-legal fear being a personal threat but the over diagnosis and excess cost is a public or other person's burden.

2) Time pressure; I think this applies to private practice and community settings as well as in ED departments. It is often a false economy. Continuity of care is a key solution as it allows you to use time and clinical review to aid the diagnosis and more appropriate investigation. ED settings are an inferior setting for care for many conditions because of the lack of continuity of care.  Better links and better shared care between ED departments and ongoing primary care settings , (General Practice) would help this.

3) Pressure to get people out of expensive hospital based care: There is an additional case for doing more extensive and expensive investigations if it might lead to being able to send a person home rather than admit them to hospital. In this you have to balance the risks/ harm from being admitted (hospital acquired infection/ misadventure etc) vs the risk of  harm from over diagnosis.

4) Sometimes inappropriate guidelines based on specific conditions rather than whole person care in the context of multi-morbidity.

Teaching clinicians to consider the likelihood ratios for a test as well as the sensitivity and specificity would help.