Wednesday, October 09, 2013

A technological paradox

An article published in the medical literature in 2011 documented a significant increase in the number of pulmonary emboli that were diagnosed since the introduction of sensitive tests for them. The mortality associated with that condition, however, did not improve significantly over the trends that had existed prior to the adoption of more sensitive diagnostic methods. The number of complications associated with therapy of pulmonary embolism did increase in the same manner as the number of diagnoses. The implication of this is that the introduction of sensitive diagnostic technology led to a dramatic increase in the number of cases diagnosed, but that that increase did not have a significant impact on patient outcomes. Pulmonary embolism began to be overdiagnosed, and some patients experienced significant complications from therapy that previously would have been unnecessary.

This circumstance is not limited to pulmonary embolism, nor to a small number of similar conditions. Diagnostic technology has advanced to the point that resolution of diagnostic studies has out-paced our ability to interpret them. We are finding more minute and unanticipated anomalies for which we do not know the significance. As a result, physicians are making diagnoses, often based on incidental findings, and providing treatments where they would not have only a few years ago. The benefits and risks associated with making these diagnoses and treating these patients is unclear. In the case of pulmonary embolism, increase diagnostic sensitivity clearly carries the risk of overdiagnosis, providing treatment where none is required, and causing unnecessary complications.

The tendency to overdiagnosed and over treat arises not only from technological advancement. Fear of litigation, patient expectation, and the proliferation of protocols and algorithms also influences medical decision-making in the direction of more frequent and less efficacious treatment. Paradoxically, while diagnostic technology enables greater detail of unclear significance, the use of protocols and algorithms homogenizes diagnostic data and disregards other clinical information of significance to a particular patient.

These factors contribute to an undesirable praxis in American medicine. The desire to provide diagnostic certainty when there actually is none, to medicalize everyday difficulties and consider them as diseases leads to such excesses as overprescribing antidepressants and stimulant medications, a proliferation of unnecessary procedures for treatment of ill-defined "syndromes," and an explosion in the number of patients claiming disabilities of one type or another. A peculiarity of American medicine is that many diseases and medical conditions are associated with their own interest groups. Diseases have lobbies. It is an undeniable and likely inescapable fact of American medicine that some interests benefit from overdiagnosis and overtreatment, and those interests are active in perpetuating what is fundamentally bad medicine.

This is only one of an innumerable number of factors for which the affordable care act provides no answer.

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