Hosted by acclaimed journalist and health researcher Dr Ray Moynihan, The Recommended Dose tackles the big questions in health and explores the insights, evidence and ideas of extraordinary researchers, thinkers, writers and health professionals from around the globe. The series is produced by Cochrane Australia and co-published with the BMJ.
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Dr Ray Moynihan’s guest has led something of a double life, using both medicine and the media to explore and promote the critical role of evidence in healthcare. Now based at the University of Sydney, Alexandra Barratt‘s journey from clinician to journalist to global advocate for evidence based medicine and shared decision-making is a fascinating one.
Here Alexandra talks with Ray about her varied career and the reasons she’s ended up challenging conventional wisdom. She also talks about her research into the pros and cons of breast cancer screening and questions the widely-accepted idea that early detection is always the best medicine.
Loose disease definitions cause millions misdiagnoses and excess testing/treatment. Checklist stops disease mongering
A landmark paper addressing overdiagnosis, published yesterday in the journal JAMA Internal Medicine, outlines the first serious attempt to set some global rules for those experts who move diagnostic goalposts that label more people as sick.
No guidelines exist currently for guideline panels and others considering changes to disease definitions. Panels frequently widen disease definitions, increasing the proportion of the population labeled as unwell and potentially causing harm to patients. We set out to develop a checklist of issues, with guidance, for panels to consider prior to modifying a disease definition.
“Medical science is making so much great progress soon none of us will be well” Allen Frances
We assembled a multidisciplinary, multicontinent working group of 13 members, including members from the Guidelines International Network, Grading of Recommendations Assessment, Development and Evaluation working group, and the World Health Organisation. We used a 5-step process to develop the checklist:
a literature review of issues,
a draft outline document,
a Delphi process of feedback on the list of issues,
a 1-day face-to-face meeting,
and further refinement of the checklist.
The literature review identified 12 potential issues. From these, the group developed an 8-item checklist that consisted of definition changes, number of people affected, trigger, prognostic ability, disease definition precision and accuracy, potential benefits, potential harms, and the balance between potential harms and benefits. The checklist is accompanied by an explanation of each item and the types of evidence to assess each one. We used a panel’s recent consideration of a proposed change in the definition of gestational diabetes mellitus (GDM) to illustrate use of the checklist.
Conclusions and Relevance
We propose that the checklist be piloted and validated by groups developing new guidelines. We anticipate that the use of the checklist will be a first step to guidance and better documentation of definition changes prior to introducing modified disease definitions.
Sources and Media Releases
Changes in Disease Definition and Prevalence of a Condition, Wiser Healthcare, 04:59 – 16 mai 2017.
Checklist of Items to Consider When Modifying a Disease Definition, Wiser Healthcare, 03:31 – 16 mai 2017.
The threat to human health posed by overdiagnosis and the waste of resources on unnecessary care
In 2002 the BMJ published a theme issue called “Too Much Medicine?” with articles on the medicalisation of birth, sex, and death, among other aspects of ordinary life. Its opening editorial wondered whether doctors could become pioneers of de-medicalisation, handing back power to patients, resisting disease mongering, and demanding fairer global distribution of effective treatments.
A decade later, as data on overuse and overdiagnosis mount the BMJ announces its Too Much Medicine campaign aiming to highlight the threat to human health posed by overdiagnosis and the waste of resources on unnecessary care.
There is growing evidence that many people are overdiagnosed and overtreated for a wide range of conditions, such as prostate and thyroid cancers, asthma, and chronic kidney disease.
Through the campaign, the journal plans to work with others to increase awareness of the benefits and harms of treatments and technologies and develop ways to wind back medical excess, safely and fairly. This editorial by Fiona Godlee, editor in chief of The BMJ and overdiagnosis researcher Ray Moynihan, senior research fellow at Bond University, Australia, explains more about the campaign:
Dr Godlee said: “Like the evidence based medicine and quality and safety movements of previous decades, combatting excess is a contemporary manifestation of a much older desire to avoid doing harm when we try to help or heal.
Making such efforts even more necessary are the growing concerns about escalating healthcare spending and the threats to health from climate change. Winding back unnecessary tests and treatments, unhelpful labels and diagnoses won’t only benefit those who directly avoid harm, it can also help us create a more sustainable future.”
The BMJ was a partner in the international scientific conference, Preventing Overdiagnosis, held in September 2013 in Hanover, New Hampshire. The conference brought together the research and researchers, advanced the science of the problem and its solutions, and developed ways to better communicate about this modern epidemic.
How the World’s Biggest Pharmaceutical Companies are turning Us All into Patients
A lot of money can be made from healthy people who believe they are sick. Pharmaceutical companies sponsor diseases and promote them to prescribers and consumers. Thirty years ago, Henry Gadsden, the head of Merck, one of the world’s largest drug companies, told Fortune magazine that he wanted Merck to be more like chewing gum maker Wrigley’s. It had long been his dream to make drugs for healthy people so that Merck could “sell to everyone.” Gadsden’s dream now drives the marketing machinery of the most profitable industry on earth. Drug companies are systematically working to widen the very boundaries that define illness, and the markets for medication grow ever larger. Mild problems are redefined as serious illness and common complaints are labeled as medical conditions requiring drug treatments. Runny noses are now allergic rhinitis, PMS has become a psychiatric disorder, and hyperactive children have ADD. When it comes to conditions like high cholesterol or low bone density, being “at risk” is sold as a disease. Selling Sickness reveals how widening the boundaries of illness and lowering the threshold for treatments is creating millions of new patients and billions in new profits, in turn threatening to bankrupt health-care systems all over the world. As more and more of ordinary life becomes medicalized, the industry moves ever closer to Gadsden’s dream: “selling to everyone.”
Ray Moynihan, Iona Heath, and David Henry give examples of disease mongering and suggest how to prevent the growth of this practice. Selling sicknes book is organized as a series of case studies, each focused on a particular drug. Each chapter explores a different aspect of drug marketing, with evidence drawn from published editorials, news reports, academic journals, and, most interestingly, original interviews with physician-spokespersons and pharmaceutical sales experts.