Dhruv Khullar on overdiagnosis

Mark Gusack gusackm at COMCAST.NET
Wed Nov 14 21:54:03 UTC 2018


Good Afternoon Everyone:

 

Unfortunately money has always had some influence on both the diagnostic process and the actual diagnosis itself.  Although I have occasionally seen some lukewarm articles on this, there has not been any systematic review.  And, for good reason.  There are too many vested interests in this field of endeavor to allow for this to happen.

 

Here are just a few issues of many that I have observed or been affected by during the last forty years of Pathology Practice:

 

Pap smears loss leader and liability issues: Reference laboratories often undercharge for the Pap smear to attract clients and to assure the client sends any follow up biopsies for smears reported out as positive.  This leads to monetary issues.  First resource starvation of the Pap smear operation to minimize that loss.  This leads to an increase in misdiagnosis.  Then, there is the tendency to over diagnose atypia and dysplasia.  And, there are two complimentary reasons for this:  Liability costs for a missed diagnosis.  Increasing follow on income from biopsies to offset the Pap smear loss through increased numbers of follow up biopsies.  At one reference lab, as medical director, I safely reduced our Pap smear calls by half.  Instead of being praised, I was  accused of taking away profits because I had reduced follow on biopsy specimens by half…

 

Prostate biopsies: There has been a systematic rise in the number of separate biopsies taken from the prostate from two – one from each side – to six – three from each side – to up to fourteen!  Each separate container generated allows for separate CPT coding at the laboratory and this greatly multiplies the billing.  At some laboratories, the submitting physician is ‘rewarded’ for doing so.  Despite what is stated in the pathology literature, when I have had the chance to collate data on six versus 12 – 14 biopsies, I find there is no difference in the number of positive diagnoses.  This is because most urologists will take 2 – 3 cores per biopsy when doing six while they tend to take just one core per biopsy when doing the 12 – 14 biopsies.  So, the total tissue sampled is virtually the same.

 

Liability costs:  Unfortunately I have noted over the past forty years that the potential for monetary loss due to wrong diagnoses has driven diagnostic criteria and application of those criteria.  The problem is as follows:

 

If a pathologist calls cancer and the patient does not have cancer, the result is what appears to be a cure after treatment.  The pathologist is a hero!  Whereas, if a pathologist calls benign and the patient returns with metastatic cancer, there is going to be a law suit.  The pathologist is a goat!  This happens even if the metastatic tumor cannot be linked causally to the first lesion called benign.  I have seen this where the first biopsy was not only called benign by the primary pathologist but was also called benign by an expert prior to the return of the patient with cancer.

 

In my experience, the three most overcalled cancers are: Thyroid, breast, and prostate.  Very early malignant melanomas may be another.  However, melanomas can be difficult to diagnose because there are no reliable criteria to rule them out.  Only criteria to rule them in.

 

Yes, unfortunately monetary incentives have both a direct and indirect impact on what happens to the diagnosis.

 

Mark Gusack. M.D.

President

MANX Enterprises, Ltd.

304 521-1980

www.manxenterprises.com <http://www.manxenterprises.com> 

  

 

From: Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG> 
Sent: Wednesday, November 14, 2018 2:12 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Dhruv Khullar on overdiagnosis

 

Thanks Helen,

 

Important post.

 

Is money a driver for any of these diagnoses?

 

Which brings up the argument as to how big an issue money is in the diagnostic process. 

 

Many years ago there used to be concerns in the medical community about certain surgical procedures being done so frequently by some.

 

Is there literature that discusses the influence of money on diagnosis and has SIDM ever considered it in their positions and writings?

 

Rob Bell M.D.

 

 

 

On Wednesday, November 14, 2018, 9:04:11 AM MST, Helen Haskell <haskell.helen at GMAIL.COM <mailto:haskell.helen at GMAIL.COM> > wrote: 

 

 

https://www.nytimes.com/2018/11/06/well/live/a-profusion-of-diagnoses-thats-good-and-bad.html

 

"A central problem is that medicalized diagnoses often come with medicalized treatments: Our penchant for pills outstrips even our desire for diagnosis. Since the 1990s, the number of office visits for sleep problems has doubled, and diagnoses of insomnia have increased sevenfold. But prescriptions for sleep medications have increased more than 30 times.

This is perhaps most concerning for children. About 12 percent of children in America now carry a diagnosis of A.D.H.D, and there was a 40-fold increase in childhood bipolar disorder diagnoses between 1994 and 2003. Five times as many children are now prescribed psychostimulant and antipsychotic medications as were in the 1980s. Today, a quarter of children and teenagers take prescription drugs regularly, and seven percent of older adolescents and young adults report abusing opioids — most of whom were initially prescribed them by a doctor."

 

Also Lown:

https://lowninstitute.org/news/blog/when-diagnosis-becomes-dangerous-a-taxonomy-of-medicalization/


"More newly recognized diagnoses is not inherently a good or bad thing. But we need to look deeper at this pattern – who is creating these diagnoses, who they are affecting, and how they are treated – to better understand how some diagnoses can be helpful and others harmful."

 

 

 

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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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