Can Hippocrates prevent overdiagnosis?

Hippocrates' famous oath echoed around Barcelona's International Convention Centre throughout the fourth Preventing Overdiagnosis conference, held this past week. For three days, this eclectic and passionate mix of policy makers, clinicians, academics and patients discussed modern medicine's divagation from its binding principle: primum non nocere (first do no harm).

28 sept 2016--Dr. Catherine Calderwood, the Chief Medical Officer for Scotland, best encapsulated the spirit of the conference. Dr. Calderwood's keynote presentation highlighted the fundamental goal of all health care: person-centred care. Building on her Realistic Medicine report, Dr. Calderwood argued that effective, appropriate care is one that gives person preference (she prefers this term over patient preference) paramount importance. "I wanted to stand on my doorstep and talk to my neighbor," she recalls from an anecdote with a patient, "I wanted a grab rail to help me stand. I went to the doctor, I still don't have a grab rail, but I have a knee replacement and I still can't talk to my neighbor." Anecdotes such as this emphasise why we were all there: to re-focus on improving the health of people, rather than reflexively treating the conditions of patients." Clearly passionate about the health of Scottish people, Dr. Calderwood's conclusion resonated profoundly around the conference auditorium: 'Is it really part of your Hippocratic Oath to list someone for a procedure rather than talk them through why they don't need it?'
This fourth edition of the Preventing Overdiagnosis conferences felt like a landmark: 30% more abstracts were submitted than last year, and attendance was a record high. The three previous conferences focused largely on establishing whatoverdiagnosis is and its prevalence within our health care systems; cancer and incidental radiological findings dominated much of the discussion. Encouragingly, this year's meeting captured some of the successful follow up work of the previous years. Professor William (Bill) Black's insight into the influence of overdiagnosis and incidental findings on the forthcoming Fleischner Society Radiology guidelines, a USA-based organisation that produces guidance for radiologists reporting chest imaging, reflects the impact of these meetings and their surrounding research. Further, the quantification of a 'reservoir' of indolent cancer – cancer that grows, slowly and asymptomatically – via meta-analyses of autopsy studies has reinforced the hypothesis that we are finding cancer that patients will die with rather than from. We can be more assured in our belief that cancer exists on a spectrum and its natural course is not universally fatal.
New focuses at this year's conference included genetic testing, a more critical assessment of clinical practice guidelines, and strategies to reduce unnecessary care. Genetic testing has always lingered in the background of these conferences, often viewed apprehensively. Professor Chris Semsarian, a genetic cardiologist, allayed fears and offered great insight into the consideration taken when a genetic test is ordered and its results interpreted. Although genetic mutations of unknown significance (variants of unknown significance (VUS)) are still common, genetic-based care may still prove to be a solution to unnecessary care; the potential of precision medicine still beckons.
Clinical practice guidelines were also examined thoroughly. Often considered a benchmark of care quality, numerous methodological issues surrounding guidelines were raised, including panelists' conflicts of interest. The #showmorespinecampaign presented a novel and innovative approach to improve vertebral fracture guidelines. According to Teppo Järvinen and colleague's presentation, the problem is clear: '75% of osteoporosis guidelines do not take a stand on what cut-off point (criteria) should be used when diagnosing vertebral fractures', the consequences are also evident: '75% of osteoporosis treatment guidelines state that all vertebral fractures warrant osteoporosis medication'. The solutions remain difficult, but I applaud and colleagues' approach and look forward to following (and supporting) their campaign (see more here).
To truly mitigate the harm from too much medicine, effective strategies to reduce unnecessary testing and treatment must be established. Our conference hosts, Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS), have given these issues much thought and the sophistication of their public health campaigns within Catalonia reflect this. Their multi-level strategy to develop recommendations to improve care, based somewhat on the NICE Do Not Do guidelines, are already yielding improvements in the health of their people.
With our Hippocratic duty resonating amongst the delegates, the 2016 conference ended with a look ahead to the 2017 Preventing Overdiagnosis host, Quebec City, Canada. A year shall provide ample time for this enthused group to continue to fend off the unnecessary harms of too much medicine.

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