With the perennial pressure on the national health budget preoccupying the Minister for Health and his mandarins at present as they attempt to extract as much money as possible from the Minister for Finance in the upcoming Budget, there is one area they could well focus on as a cost-saving measure: overdiagnosis.
Overinvestigation and overtreatment are a feature of modern medicine. Overdiagnosis has been defined as occurring when people are diagnosed with conditions that will never cause symptoms or shorten their lifespans.
There are many factors potentially driving overdiagnosis: new technology in the form of scans and novel blood tests; less tolerance of medically unexplained symptoms by doctors and patients; higher levels of litigation against doctors driving some to overinvestigate; and the media and greater access to the internet.
Medically unexplained symptoms are defined as “persistent bodily complaints for which adequate examination does not reveal sufficient explanatory structural or other specified pathology”. They are a common presentation, accounting for as many as one in five new consultations in primary care.
Unexplained symptoms
The topic was the subject of a recent workshop for continuing medical education tutors in general practice. Sligo/Leitrim tutor Dr Frank Hayes explains how it is difficult for doctors treating people with medically unexplained symptoms to find a balance between appropriate investigation, explanation and reassurance, and overinvestigation with the attendant risk of causing harm to the patient.
Patients can find it hugely frustrating when symptoms remain unexplained and cannot be given a diagnostic label. One of the most important issues for patients is that a doctor listens to their story. They must feel their symptoms are real and being taken seriously. Explanation and reassurance should not involve telling the patient that there is nothing wrong, as clearly this is not the case and may even make symptoms worse.
Hayes says he finds it useful to think about these as problems with function in the body rather than with its structure and that this approach can start making sense of the symptoms for patients. But patients find it threatening and upsetting if medically unexplained symptoms are attributed solely to stress.
Serial investigations are unhelpful and can lead to overdiagnosis.
Research suggests medically unexplained symptoms are associated with 20-50 per cent more outpatient costs and 30 per cent greater hospitalisation rates. It is estimated the annual healthcare costs of medically unexplained symptoms in the UK exceed £3.1 billion (€3.9 billion).
Overinvestigation and over-referral are also the source of avoidable iatrogenic (healthcare-induced) harm. Cat scans involve significant doses of radiation; tests involving the injection of dyes into the body may trigger an allergic reaction; and the ever-present risk of a false positive result to any medical test can itself trigger an avalanche of further unnecessary investigations.
Doctors are advised to be explicit about their expectations when referring a patient for investigation or for another opinion. It’s important they are open about their uncertainty while reassuring the person that a serious cause is unlikely. But the patient must be told the doctor has an open mind and will continue to reassess the symptoms in the future. And even without a diagnosis, there is much that can be done to ameliorate symptoms and improve functioning.
“If these symptoms are managed well, this will have considerable benefits for patients and make better use of finite healthcare resources,” Hayes says. “GPs have the best skillset to manage these problems because of the continuity of care and trust they can establish in their relationships with patients: they are the specialists in this area.”
The continued under-resourcing of primary care in the context of overdiagnosis is something the Minister might reflect on in the run-up to the Budget. With highly skilled GPs leaving the country, healthcare costs appear likely to rise at the same time as patient outcomes deteriorate. mhouston@irishtimes.com muirishouston.com