BJGP LONG READ ‘Delicate diagnosis’: avoiding harms in difficult, disputed, and desired diagnoses, BJGP Life, 7 October 2022

https://bjgplife.com/delicate-diagnosis-avoiding-harms-in-difficult-disputed-and-desired-diagnoses/

BJGP LONG READ
‘Delicate diagnosis’: avoiding harms in difficult, disputed, and desired diagnoses

7 October 2022

Margaret McCartney is an Honorary Senior Lecturer at the School of Medicine, University of St Andrews.

Natalie Armstrong is a Professor of Healthcare Improvement Research at the Department of Health Sciences, University of Leicester.

Graham Martin is Director of Research at The Healthcare Improvement Studies Institute, University of Cambridge.

David Nunan is a Senior Research Fellow at the Nuffield Department of Primary Care Health Sciences, University of Oxford.

Owen Richards is Chair of the Patient and Carer Partnership Group, Royal College of General Practitioners.

Frank Sullivan is a Professor of Primary Care Medicine at the School of Medicine, University of St Andrews.

Medical diagnoses can be subject to ambiguity, flux, subjectivity, and inherent uncertainty. This is particularly true in primary care, where many reported symptoms do not conform to a clear diagnosis. Thresholds around normality are often unclear.

Symptoms are commonly experienced and described as an ’iceberg’. Over a third of otherwise well people without a chronic condition have felt tired or run down, or had a headache in the previous 2 weeks, and over a quarter have had back or joint pain.1 Distinguishing conditions that would benefit from diagnosis and earlier intervention from those that are temporary, self-limiting, and prone to harmful medicalisation, remains challenging.

While overdiagnosis is a diagnosis of a condition that, if unrecognised, would not cause symptoms or harm, contested diagnoses are symptoms given a diagnosis, but where the diagnosis, as an explanation for them, is controversial. Opponents consider contested diagnoses ‘wrong’ not because of an error in history taking, clinical examination, or interpretation of a test result (which would risk misdiagnosis), but because the diagnosis itself, for example, chronic Lyme disease or multiple chemical sensitivity, is invalid.2,3 etc.

 

They fail to even consider the widespread phenomenon of under diagnosis or especially dismissive diagnosis based on Psychology. This has resulted in countless deaths and additional suffering and such an instance is once again in the papers this week. This is far more common in the UK and its one of the primary reasons the UK has one of the worst disease burdens in the western world.

 

I read this as 'GPs muddle along without really knowing what they are doing and don't worry girls and boys it's OK to do that because a load of professors call it using Bayes Theorem and stuff and think it's great (without actually saying anything else useful).

 

Disease burden is complex and there's no reason to conclude that issues with diagnosing disease separates the UK from its comparators. One way to make comparisons across populations is to use Disability-Adjusted Life Years (DALYs) https://ourworldindata.org/burden-of-disease#the-global-distribution-of-the-disease-burden on this measure pre COVID the UK, Germany and New Zealand were almost the same, while the US tops the developed nations league, Canada and Australia are not vastly different from the UK. Spain, France and Italy, along with the four Scandinavian countries have notably lower DALYs numbers with Japan a notable outlier with by far the lowest score of any larger nation.

Of course the UK has major problems with a huge recorded burden of ill health, a likely large unrecorded burden of ill health and a Health service breaking under the strain but historically the UK has been close in health outcomes to its main comparators. Across developed countries there are two distinguishing features in terms of DALYs, one is population age (with Japan a significant outlier) and the other is lifestyle with diet being the most significant aspect.

There are undoubtedly high levels of undiagnosed diabetes, high blood pressure and coronary heart disease in the UK population - but these aren't going undiagnosed because some NHS bod is telling them they have a psych problem - it's because people are not engaging with the health service, or are ignoring all the advice regarding good diet and exercise or they lack the resources to make the necessary adaptations to their lives. Psychology and Psychiatry may have many faults but the UK's public health problems are long standing and have far more to do with societal structure than any diagnostic failures.

 

I'm guessing they don't mean CBT & GET here, or the excessive amounts of psychoactive drugs they are forcing down on us, but I am baffled as to what else they could possibly mean, since there is nothing else happening and this is obviously not our responsibility anyway. Seems like there's a lot of imagination going on about us having all kinds of medical interventions.

And overmedicalisation probably overlaps with testing, and again none of this is our fault, we can't even influence things in a way that removes harmful nonsense. It's true that extensive testing is useless here, but all of this is entirely the fault of medicine, I have no idea what they expect to happen here. This is what happens when you fail, it looks a lot like failure, because it is.

 

Could the 'burden of patienthood' be similar to the 'burden of treatment'? The latter I have heard before and take to mean the work we have to do to carry out treatment and management, including the work of coordinating, communicating, collecting, monitoring, reporting, learning, managing side effects, and so on.