Letter to the Editor: Editorial: Chance Encounters, Overdiagnosis, and Overtreatment

OpenAlex İngilizce

To the Editor: I read the Editorial, “Chance Encounters, Overdiagnosis, and Overtreatment” with great interest [5]. I want to thank the Editor for his effort to highlight the debate on this important topic. Overdiagnosis and overtreatment probably are the biggest problems in modern medical care [3, 7, 9], and they are potentiated by a complex web of forces. Many social and psychological factors contribute to physicians’ failures to abandon ineffective medical practices. These include social iatrogenesis, legal concerns, patients’ expectations, and true beliefs. I’ll cover each of these in sequence below, but the key message is this: If we are going to mitigate overdiagnosis and overtreatment, we’ll need to look at those factors, and not merely look at this through a biomedical lens. Social Iatrogenesis: Ivan Illich, the author of an article “Medical Nemesis,” used the phrase “social iatrogenesis” to describe the medicalization of society in 1974 [3]. In his words, “social iatrogenesis is a term designating all impairments to health that are due precisely to those socio-economic transformations which have been made attractive, possible, or necessary by the institutional shape health care has taken.” Advertising and awareness campaigns fuel the drive toward more diagnosis and more treatment. Media messages exert their greatest influence on the general public, but they influence doctors and their decision-making process as well. The medical-industrial complex is largely influenced by profit motives. This creates self-reinforcing cycles and promotes overdiagnosis. Legal Concerns: Ordering a test is a concrete service. Most people like being tested and very few object to it. Further, there are legal penalties for underdiagnosis (failure to diagnose), but there are no corresponding penalties for overdiagnosis. This is another factor that leads to overdiagnosis. Patients’ Expectations: Several cultural factors impact the physician-patient relationship and decision-making process. Dr. Chen says in his letter [1] about an earlier, related editorial by Dr. Leopold [6]: “Patients perceive intervention as diligence and inaction as negligence.” The desire to get a good grade from the patient is a powerful incentive for pursuing more diagnosis. And ordering a test or proposing an operation both are quick and simple; discussing with a patient why surgery might not be in his or her interest is neither. It takes time and requires explaining the problem of overdiagnosis and overtreatment. In addition, if, for example, a surgeon does not want to order an MRI to look for a degenerative meniscal tear (because the surgeon believes that treating it is unlikely to be helpful), both the surgeon and the patient need to be comfortable with some measure of uncertainty. But as it turns out, uncertainty is not well tolerated, and intolerance of uncertainty is another powerful factor for overdiagnosis. Patients perceive uncertainty as ignorance and certainty as reassurance. The physician-patient relationship has historically evolved from a paternalist metaphor to a metaphor of corporatism [8]. In this setting, surgeons have the important but challenging task of helping patients make decisions in the face of some uncertainty rather than getting diagnostic tests that won’t result in changes to care (or worse, will result in needless interventions, like arthroscopic debridement of degenerative meniscal tears in older adults). True Beliefs: When Slovenian philosopher Slavoj Zizek wrote about the vicious circle of belief, he shared, “The reasons why we should believe are persuasive only to those who already believe.” Theories of cognitive homeostasis describe how high-level beliefs shield against continuous reshaping of the brain’s model of the external world [2]. In this context, Bayesian inference is remarkably analogous to our perception (Figure 1). Bayes’ theorem describes how the observation of new data changes a prior belief (knowledge, expectation, or prediction) into a posterior belief [2]. This posterior belief represents the inference about the most likely cause behind the observed data, given the previous knowledge (Figure 1), and becomes the new prior belief or prediction based on future observations. But changing one’s beliefs requires great effort. In addition, the illusion that we understand the past fosters overconfidence in our ability to predict the future. After all, the brain does not “represent” but rather creates our world [4].Fig. 1: The graph shows Gaussian probability distributions that represent prior beliefs (knowledge, expectation, or prediction), posterior beliefs (updated belief), and the likelihood of evidence (observed data, sensory input).Finally, we need to be honest enough to admit that we might be wrong in some situations. Most of what has been “known” at one time or another has eventually turned out to be wrong. All scientific knowledge is tentative and provisional; it’s never final. Science changes all the time, and not through the accretion of new certainties. The currently accepted theory of a phenomenon is simply the best explanation for it among all available alternatives. While the human ability to understand may be in a certain sense unlimited, existing scientific concepts can only cover a very limited part of reality; the remainder, which is not yet understood, is infinite. Whenever we proceed from the known into the unknown, we may hope to understand, but we may have to learn at the same time a new meaning of the word “understanding.”