Overdiagnosis

Several factors contribute to overdiagnosis, including:

• commercial interests
• technological advances
• expanding disease definitions
• cultural influences and consumer behaviour
• clinician behaviour.^1-3

There are a number of patient harms that result from overdiagnosis,^2,4 including:

• Physical harm from unnecessary treatment: This includes surgical complications and side effects of medication
• Financial costs of unnecessary treatment: These include out-of-pocket payments for procedures, as well as time off work for tests, treatments and recovery, and loadings and exclusions that insurance companies might apply as a result of particular test results
• Stress and anxiety for patients, their families and carers: This could include concerns about having a ‘diagnosis’, stress related to the outcome of serious procedures and anxiety about the real (or potential) loss of quality of life
• A cascade of follow-up tests and/or treatments: An ‘abnormal’ test result may lead to further tests, such as biopsies
• Harms to other patients from an overburdened health system: Excess demand reduces the availability of valuable resources for people who need urgent care.

• Implement watchful waiting: This can often be safely implemented by monitoring the patient’s condition, but not providing treatment immediately.⁵ To implement properly:
  • advise your patient of symptoms they should look out for, especially red flags⁶
• depending on the condition, ask your patient to return at an agreed time for a review, or sooner  if symptoms appear, get worse or change
• reassure your patient that they can take time to think about the information they have received  and return if they have any questions.
• Communicate the harms and benefits of the test or treatment:
  • Use  reliable, patient-friendly information so the patient understands the risks and benefits of the test or treatment they are asking about and can make informed decisions.²
  • Provide further information about appropriate diagnostic testing, such as the RACGP’s Appropriate diagnostic testing patient information sheet, which has more information on this topic.
  • Use precise language when talking about screening and diagnosis (eg use the term ‘raised blood pressure’ instead of ‘hypertension’).²
  • Depending on the test or screening being discussed, talk to your patient about:
    • the uncertainties in medicine and the advantages of not rushing to a diagnosis²
    •  the high sensitivity of modern screening tests.² Some screening tests can detect an ‘abnormality’ that many people have but is not the cause of your patient’s symptoms, and will not cause them any harm. Such a test result not only may create an unnecessary ‘diagnosis’, along with the associated unnecessary harms, but it can also mean that the GP and patient stop focusing on  the cause of the symptoms.
• Seek informed consent from patients for cancer screening tests: It is estimated that approximately 18–24% of cancers in Australia are overdiagnosed.⁴ Therefore, it is important that the patient provides informed consent for cancer screening tests after careful consideration of the potential harms and benefits.
• Write to practitioners of complementary and alternative medicine (CAM): If a patient requests an inappropriate test that a CAM practitioner has recommended, consider writing to the CAM practitioner to explain why the test was not undertaken. An MS Word version of a template letter the RACGP developed  is available to download here.
• Undertake a comprehensive clinical assessment, focusing on the patient’s history, lived experience and physical examination as appropriate. Do not over-rely on sensitive medical technologies that may highlight ‘incidentalomas’.²

RACGP First do no harm GP resources, Management of subclinical hypothyroidism

RACGP clinical resources

• Guidelines for preventive activities in general practice (the Red Book)
• National guide to a preventive health assessment in Aboriginal and Torres Strait Islander people
• Responding to patient requests for tests not considered clinically appropriate
• RACGP Standards for general practices (5th edition) RACGP position statements, Too much medicine newsGP articles
• GPs to lead the charge against ‘too much medicine’
• Too much medicine harming patients, experts warn
• The Good GP podcast, Incidentalomas

Other resources

• Wiser Healthcare, What is overdiagnosis?
• General Practice Supervisors Australia, Managing uncertainty in general practice guide
• Choosing Wisely Australia, Choosing wisely in general practice
• The Conversation, Five warning signs of overdiagnosis
• World Health Organization, Screening programmes: A short guide

RACGP First do no harm GP resources, Management of subclinical hypothyroidism

Other RACGP resources

• Appropriate diagnostic testing – patient information
• Should I have prostate cancer screening?

Other patient resources

• Wiser Healthcare, What is overdiagnosis?
• Wiser Healthcare, Questions to ask a health professional
• Informedhealth.org, What is overdiagnosis?
• Choosing Wisely Australia, 5 questions to ask your doctor or other healthcare provider before you get  any test, treatment, or procedure