Overdiagnosis and overmedicalization: Turning data into reduction
From left to right: Dre Geneviève Bois, Dre Guylène Thériault et Dr René Wittmer
Photo credit: @GenBois
Dr. Guylène Thériault, who has been a family physician since 1996, and is a graduate in evidence-based healthcare from Oxford University in England and a founding member of Choosing Wisely Canada’s clinical leaders group, has made it her mission to reduce overdiagnosis and overmedicalization. In addition to her clinical duties and research interests, Dr. Thériault has taught evidence-based medicine and shared decision-making to students, residents and physicians for several years. She has also been a member of the Québec Medical Association’s Board of Directors since April 2016. It was in this capacity that she attended the 6th international Preventing Overdiagnosis conference, held in Copenhagen from August 20 to 22, 2018. The QMA asked Dr. Thériault to discuss her experience at the conference and to describe her vision of the ongoing fight against overdiagnosis and overmedicalization.
QMA: You attended the 6th international Preventing Overdiagnosis conference in Copenhagen last August as a representative of the QMA, is that correct?
Dr. Thériault: Yes, Dr. Yun Jen and I both attended as representatives of the QMA. Along with Dr. Geneviève Bois of the Québec College of Family Physicians and Dr. René Wittmer, a facilitator for the Practising Wisely: Reducing Unnecessary Testing and Treatment program, we presented the findings from Québec. In preparation for the conference, we analyzed data from the past year. We found that six weeks after having participated in the Practising Wisely workshop, over 94% of participants had modified at least one of their practices, which was astonishing. After twelve weeks, we asked them if they had modified a second practice, and almost 83% had done so.
Graphs extracted from the analysis of surveys from the
Practising Wisely: Reducing Unnecessary Testing and Treatment program.
QMA: How did the participants react to your presentation?
Dr. Thériault: Very well. We received several questions as well as three requests to share our training program, specifically from Israel, the United States and the Netherlands.
QMA: This was the 6th edition of Preventing Overdiagnosis. Have you seen any progress in the fight against overdiagnosis and overmedicalization on an international scale?
Dr. Thériault: While it’s true that knowledge has continued to evolve, there has not been much advancement in the tools we have to fight the phenomenon. I attended a workshop in which we discussed how concepts related to this issue could be incorporated into medical programs from day one to become an integral part of training at all levels. However, the conversation quickly reverted to simply adding a curriculum—a few hours here and there—to the general program. The problem is that this will never solve the issue of the hidden curriculum. It’s a well‑known fact that young people learn mainly by watching what other physicians do.
QMA: Would you prefer that overdiagnosis and overmedicalization be discussed in each of the disciplines they are taught?
Dr. Thériault: If students are told to perform this, that and the other test for each type of disease, they will of course learn them by heart. But if we instead discuss the relevance of each of the tests, their usefulness and the cases in which they are really necessary, future physicians will take a different approach. For example, there are many tests that can be done for fatty liver, but the treatment is always the same: The patient has to lose weight and eat well. So, rather than teaching physicians a formula, it may be more appropriate to teach them to ask themselves whether the test they want to prescribe will change the treatment or the patient’s well-being.
QMA: So the idea would be to integrate the question of relevance throughout the curriculum?
Dr. Thériault: I know it may sound utopian, but I’m fortunate enough to be involved in McGill University’s satellite faculty of medicine project in the Outaouais region, and I’m hopeful that we’ll be able to do things differently. I suggested the idea of providing specific training to the instructors—rather than the students—to make them aware of the issues and to ensure that they are able to integrate notions of relevance into their course content. We can design curricula for young people, of course, but I’m not sure that’s the way to change the professional environment, if the instructors themselves are not aware of the issues of overdiagnosis and overmedicalization.
QMA: Any other observations?
Dr. Thériault: At last year’s conference in Québec City, I found it interesting to hear from patients who were given the opportunity to speak to participants and to share their insights, but this was not repeated in Copenhagen. However, although no patients were present this year, the lineup of speakers was excellent. I also discovered that we’re not alone in having trouble engaging decision-makers on the matter of reducing overdiagnosis. In France, for example, there is controversy over their systematic breast cancer screening program. In 2015, Marisol Touraine, then minister of social affairs and health, ordered an independent report on France’s national breast screening program. She was looking for recommendations, given that only 52% of women underwent the systematic screening and that its relevance was being increasingly questioned in the scientific literature. The report concluded that there were two options: either put an end to the systematic screening program altogether, or rethink it to specifically target women at higher risk. In the end, the report was shelved for political reasons and the screening program has carried on unchanged.
QMA: So, have we hit a wall on this issue?
Dr. Thériault: While it’s useful to understand what’s going on and to advance knowledge through studies, we need to find ways to change the situation on the ground. We’re still not going far enough in asking ourselves how we can change existing practices. In Québec, and probably elsewhere, we still haven’t caught the attention of policy makers, in my opinion. At some point, the guidelines will have to come from above. If we had a minister who truly believed that overdiagnosis and overmedicalization were a problem, we could move forward. It’s one thing to identify and acknowledge an issue, but in order for the relevance committees to do their work, what’s needed is a clear direction.
QMA: Is progress still being made?
Dr. Thériault: Definitely. I recently read a newspaper article on the underutilization of medical imaging equipment that talked about the issue of relevance. Of course, it stated that more machines and more money are needed, but for the first time there was mention that irrelevance leads to overuse, overdiagnosis and overtreatment. I was glad because it showed that the message is getting through. The challenge is to follow through with effective action. Many clinicians and CPDPs have good ideas, but they are often not well received. In my experience, these initiatives are more often blocked by the administration than by physicians. Even if we replace an unnecessary test with a useful one, it’s still a test, and the equipment continues to be used just as often and there’s no direct effect on any specific budgetary item. On the other hand, any change to the status quo requires investment, so there must be a real willingness to do things differently and a deep understanding of the issue of overdiagnosis.
QMA: So, is it difficult to get people to take action?
Dr. Thériault: It’s not the same everywhere. In some of the places where I presented my ideas, actions were taken very quickly. It all depends on the environment. Not all managers are yet sufficiently aware of the issue of overdiagnosis and its effects on patient health. Some only see it from an accounting perspective. In their view, relevance doesn’t save money and in a way, that’s true. Let’s say a hospital has the capacity for 30,000 tests, but there’s a waiting list of 60,000 patients. Even if 30,000 non-relevant cases are taken off the list, the machine will still be running at full capacity. I can tell managers that they’ll save money in the end because relevance will ensure patients receive more appropriate treatment, but the way some decision-makers see it is that the same number of technicians will still be needed to perform the tests and, in addition, changing practices will take time and resources. It may be time to target managers and decision-makers in training sessions and conferences on overdiagnosis and overmedicalization, the same way patients were involved in the discussion at the 5th international Preventing Overdiagnosis conference that the QMA held in Québec City.
QMA: What can patients do to address this issue?
Dr. Thériault: Patients have a lot of power to change doctors’ habits. If they ask, “Doctor, do I really need this test?” their physicians will start asking themselves the same question. There may be a small number of physicians who will tell patients they shouldn’t ask questions, but they’re in the minority. The majority of physicians will wonder if there's more to the question...if there’s something else they should know. A long time ago, I started teaching my students to ask themselves questions about the cases they were seeing and to look for answers in the literature. After a few months, their bosses came to me to find out what I was teaching the students. They wanted to learn it too! It’s the same thing with patients. If they start asking questions, physicians will want to answer them, and if the physicians need more information, they will search for it or attend training sessions in order to be able to answer their patients’ questions.
Good to know
Dr. Thériault maintains a website with tools to help practitioners incorporate preventive practices in a clinical setting. Her Centre pour l'avancement des soins de santé factuels is intended as a starting point for the creation of a centre for evidence-based medicine in Québec.