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Overdiagnosing, overtesting causing harm

The first New Zealander elected to lead the peak body for emergency medicine in New Zealand and Australia says there are a lot of things being done in medical practice that are not supported by evidence and are not free from harm.

Waikato Hospital emergency physician Dr John Bonning will become the first New Zealand president of the Australasian College for Emergency Medicine in 2019. He is also the new chair of the Council of Medical Colleges.

He and the clinical lead for New Zealand’s Choosing Wisely campaign, Dr Derek Sherwood, attended the annual Choosing Wisely International Roundtable in Switzerland in September. Dr Bonning also attended the annual Preventing Overdiagnosis conference in Copenhagen in August.

Dr Bonning says Choosing Wisely is about resource stewardship, sustainability of our public health system and reinvestment of the resources saved by reducing unnecessary tests, treatments and procedures

“Sustainability and equity of the health system and resource stewardship, along with sustainability and wellness of emergency department clinicians, were the pillars of my election policy platforms for both my new roles and I’m very passionate about Choosing Wisely.”

He says Choosing Wisely is not about rationing. “We already have rationing in our health system with waiting lists for clinical assessments and some operations. Not everyone can get their gall bladder taken out the moment they need to or their hernia fixed or their varicose veins done, or even the joint replacement they need without being assessed then prioritised along with other patients.

“This is about the best use of health money – applying resources to those in greatest need and reinvestment of money saved. For clinicians, it means thinking about the need for every single test, treatment or procedure and the ramifications for a patient with very low risk of disease of a false abnormal test.

“Overdiagnosis is turning people into patients by unnecessarily identifying issues that were never going to cause them any harm. Sometimes it is medicalisation of ordinary life experience.

Choosing Wisely encourages health professionals and patients to question unnecessary tests, procedures and treatments and suggests patients should ask four key questions:

1. Do I really need to have this test, treatment or procedure?
2. What are the risks?
3. Are there simpler, safer options?
4. What happens if I do nothing?

Dr Bonning says, for example, everyone who has a CT scan should give informed consent and know why they need the scan, what the possible benefits are, but also the potential harms.

“You must not CT scan everyone who has a knock on the head, even if they were knocked out, unless the clinician uses a validated decision instrument supported by evidence that the scan needs to be done.

“There are distinct harms of doing CT scans, including finding an incidental ‘abnormality’ that may well worry the patient. It may also initiate a ‘diagnostic cascade’ of further tests that, more often than not, show that the ‘abnormality’ is something benign that the patient was never going to either know about or suffer any health consequences from.

“They include things like a simple cyst on the kidney or liver, or a small mass in the thyroid. It is not just about the radiation dose of the CT scan. One unnecessary CT scan pushes another patient waiting for a scan further down the waiting list.”

He says ‘routine’ blood tests are another example. “In fact, I want to take the word ‘routine’ out of the medical lexicon. Routine just means ‘I don’t think about it, I just do it’. There is absolutely risk of harm in a simple blood test, which also often starts a diagnostic cascade.

“I’m not suggesting that we abandon mainstream medicine and go back to leeches. Clearly, I believe very strongly in vaccination for vaccine-preventable diseases, in antibiotics for the treatment of bacterial disease and in taking out an appendix when it’s ruptured or the patient is unwell.

“But there are certain things we do that there are lots of drivers for, including time pressure, routine, financial incentives and activity-funded health care, that have nothing to do with what’s best for the patient.

“I want every single clinician to have the Choosing Wisely mantra in the forefront of their mind in every single consultation that more is not necessarily better.”

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