Overdiagnosis and overtreatment: generalists--it's time for a grassroots revolution

Establishing a Reference Database for Select Clinical Measures in National Basketball Association Players

BACKGROUND

Musculoskeletal injuries are prevalent in the NBA and are associated with a significant number of games missed. There is a lack of reference data for clinical measures in NBA players, making it difficult for sports medicine professionals to set goals and develop programs.

HYPOTHESIS

Values for clinical measures in NBA players will differ from those of the general population but will not differ between dominant (D) and nondominant (ND) limbs.

STUDY DESIGN

Descriptive laboratory study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Clinical measures were taken on 325 players invited to NBA training camp (2008-2022). Measures included range of motion for great toe extension, hip rotation, weightbearing ankle dorsiflexion, flexibility, arch height (AH) indices, and tibial varum.

RESULTS

Clinical values for NBA players differ from reference norms of the general population. Results for NBA players include great toe extension (D, 40.4°; ND, 39.3°), 90/90 hamstring (D, 41.5°; ND, 40.9°), hip internal rotation (D, 29.0°; ND, 28.8°), hip external rotation (D, 29.7°; ND, 30.9°), total hip rotation (D, 60.2°; ND, 60.4°), Ely (D, 109.9°; ND, 108.8°), AH difference (D, 0.5 mm; ND, 0.5 mm), AH index (D, 0.310; ND, 0.307), arch stiffness (D, 0.024; ND, 0.024), arch rigidity (D, 0.924; ND, 0.925), tibial varum (D, 4.6°; ND, 4.5°), and weightbearing ankle dorsiflexion (D, 35.4°; ND, 35.6°). Descriptive statistics are presented; 2-tailed paired t tests show that, whereas most measures demonstrated differences between sides, the results were not statistically significant.

CONCLUSION

Clinical measures of NBA players differ from those reported for the general population and athletes of other sports although there were no statistically significant differences between D and ND limbs.

CLINICAL RELEVANCE

Establishing a reference database may help clinicians develop more sensitive and more effective preseason and return-to-play screening processes, aiding the management of player orthopaedic care and reducing injury risk.

To neutrally offer or strongly recommend? General practitioners' perspectives on screening for gestational diabetes according to the national guideline in Norway

OBJECTIVE

To explore general practitioners' experiences and reflections on how the current Norwegian guideline for screening for gestational diabetes affects their clinical practice.

DESIGN

A qualitive study in which data were collected through semi-structured focus group interviews and analyzed thematically.

SETTING AND SUBJECTS

Five focus groups conducted in 2020 among GPs in Norway; three interviews took place face-to-face and two were held digitally. The total number of participants was 31.

RESULTS

GPs acknowledged the potential benefits of more extensive screening, but had concerns about the medicalization of pregnancy, stating that some women experienced considerable anxiety. The GPs expressed doubts about the guideline's evidence base but differed in how they interpreted what the guideline was asking them to do. Some offered eligible women the opportunity to be screened, while other set up a screening appointment without consulting the women first. For some, fear of incrimination made them recommend screening without being convinced that it was the right thing for the patient.

CONCLUSIONS

It is unclear whether the guideline for gestational diabetes requires GPs to recommend screening to pregnant women or if they should provide neutral information about the availability of screening. This ambiguity should be addressed, and the guideline evaluated against the core principles of general practice.

Shared decision-making for supporting women's decisions about breast cancer screening

BACKGROUND

In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain.

OBJECTIVES

To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health.

MAIN RESULTS

We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured.

AUTHORS' CONCLUSIONS

Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.

Time is money: general practitioners' reflections on the fee-for-service system

BACKGROUND

Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions.

METHODS

We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis.

RESULTS

We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees.

CONCLUSIONS

GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

Increasing Knowledge in the Requesting of Clinical Investigations

PURPOSE

Overtesting, ordering diagnostic investigations that do not help diagnose or manage a patient, is well-recognized as a problem across multiple healthcare settings in developed countries. One of the reasons often cited for overtesting is a lack of confidence or knowledge, so this article addresses our attempt to reduce overtesting through an investigation-specific course for a physician associate (PA) program based in the United Kingdom. We found no evidence of pedagogical literature that focused on clinical diagnostics teaching and assessment for PAs, so we aim to be the first to provide this research.

METHODS

To assess student confidence, student feedback was collected through open-ended focus groups and qualitative surveys. The effectiveness of the course was evaluated through students' scores on investigation single best answer assessments.

RESULTS

Overall, qualitative feedback from students showed an increase in knowledge in accurate investigation requests and interpretation. Students' assessment scores show a marked improvement after the implementation of the course.

CONCLUSION

This approach to an investigation-specific course, with a focus on limiting overinvestigating, demonstrates improved student performance on investigation assessments at the university level.

Patients' views on the decision to investigate cancer symptoms in older adults: a qualitative interview study in primary care

BACKGROUND

Cancer is predominantly a disease of older adults. To date there has been little research on the experiences of older adults or their views on the diagnostic pathway.

AIM

To gain an improved understanding of the views and experiences of older adults on all aspects of cancer investigation.

DESIGN AND SETTING

This was a qualitative study using semi-structured interviews with patients aged ≥70 years. Patients were recruited from primary care in West Yorkshire, UK.

METHOD

Data were analysed using a thematic framework analysis.

RESULTS

The themes identified in participants' accounts included the patients' process of decision making, the value of having a diagnosis, the patients' experience of cancer investigations, and the impact of the COVID-19 pandemic on the diagnostic pathway. Older adults in this study indicated a clear preference for having clarity on the cause of symptoms and the diagnosis, even in the face of unpleasant investigations. Patients suggested they wanted to be involved in the decision process.

CONCLUSION

Older adults who present to primary care with symptoms suggestive of cancer may accept diagnostic testing solely for the benefit of knowing the diagnosis. There was a clear patient preference that referrals and investigations for cancer symptoms should not be deferred or delayed based on age or subjective assessments of frailty. Shared decision making and being involved in the decision-making process are important to patients, regardless of age.

The emergence of multimorbidity as a matter of concern: a critical review

Multimorbidity is considered one of the greatest emerging challenges for contemporary health care systems. However, the meaning of the term ‘multimorbidity’ is not straightforward. Despite many attempts to clarify the definition and its measurement, the concept remains elusive. Still, academic interest in the study of multimorbidity has grown exponentially in the past ten years. In this paper, we trace the emergence of multimorbidity as a ‘matter of concern’ within health care research, exploring what has been called ‘the multimorbidity epidemic’ in the context of changing disease categories. We analyse how multimorbidity as a concept lays bare some major unresolved challenges within contemporary care services and summons up traditional primary care ideals of holistic, person-centred care. However, we argue that the current focus on the measurement and the identification of disease clusters falls short in contributing to better care for people who live with multiple long-term conditions now. Instead, we propose a novel understanding of ‘multimorbidity’ as an experience that manifests through people’s navigations of care infrastructures. To study this experience of multimorbidity, we discuss the potential of social science approaches that focus on ‘living well’ with illness.

The medical model and its application in mental health

This article provides a conceptual overview of the medical model and its application to psychiatry, understanding the medical model in psychiatry as a biopsychosocial model. The article discusses basic concepts relevant to the medical model (illness, disease, disorder, condition, etc.), the nature of medical knowledge and diagnostic construct, medical classifications in psychiatry, and the medical model within multidisciplinary practice. Salient criticisms of the medical model are discussed and addressed at relevant points. It is recognized that concepts such as disease and illness lack uncontested definitions and are not free from value judgements even in general medicine. Diagnostic constructs used in psychiatry are often descriptive heterogenous categories which can nonetheless offer clinical utility. The medical model co-exists with non-medical approaches and perspectives, and psychiatrists work in an interdisciplinary context with other models and professionals. Criticism of the medical model in psychiatry often fail to recognize the continuities between psychiatry and the rest of medicine, and the persistence of these controversies may be a result of fundamental disagreement over values.

Strengthening citizenship: A healthcare improvement priority

We propose that strengthening citizenship could help realise some of the substantial changes that are being called for in mainstream health policies. We highlight the way that current healthcare improvement agendas entail, and depend upon, large-scale and complex cultural change. But, we suggest, there is a severe limit to how far such cultural change can be engineered from above or through conventional quality improvement methods. In summary, we argue that supporting what we call 'civic culture' - a culture that encourages and -enables effective citizenship - may be a precondition for -bringing about policy aspirations and related improvements.

The Pitfalls of Overtreatment: Why More Care is not Necessarily Beneficial

Overtreatment refers to interventions that do not benefit the patient, or where the risk of harm from the intervention is likely to outweigh any benefit the patient will receive. It can account for up to 30% of health care costs, and is increasingly recognised as a widespread problem across nations and within clinical and scientific communities. There are a number of inter-related factors that drive overtreatment including the expanding definition of diseases, advertising and the influence of the pharmaceutical industry, how doctors are trained and remunerated, demands from patients (and their families) and the fear of complaints leading doctors to practise defensively. This paper discusses a number of ethical and practical issues arising from overtreatment that doctors and patients should be aware of. It also considers the flow-on effects of overtreatment such as the increased cost of care, increase in work load for health professionals, and wastage as resources are diverted from more genuine and pressing needs. In addition, there are references to a number of Medical Council of New Zealand statements about what good medical practice means in an environment of resource limitation. The paper concludes with a few measures that doctors and patients could take to reduce overtreatment but acknowledges that health care is extremely complex so it would be unrealistic to eliminate overtreatment entirely.

Induced Demand in Cancer Diagnosis

Context: Supplier-induced demand (SID) is an essential concept in health economics related to the diagnosis of different types of cancer and related expenditures. The current review considered studies on induced demand in cancer diagnosis. Evidence Acquisition: This systematic review investigated the induced diagnosis of cancer in four well-known databases (Scopus, Science Direct, Web of Science, and PubMed) from January 1980 to July 2019 using the keywords “induced demand,” “cancer,” and “diagnosis”. References of the studies found through the original search were also considered for analysis. Results: No studies focused on SID in cancer diagnosis could be found, thus indicating a significant deficiency in the discussion of SID in cancer diagnosis studies. Therefore, the terms most relevant to the concept of SID in cancer diagnosis were examined. Finally, 24 factors were categorized into three groups: economic, socio-cultural, and structural. The majority of evidence for the probability of SID in cancer diagnosis is related to overdiagnosis or early diagnosis caused by unnecessary screening (57.14% of reviewed articles) and the neglect of clinical practice guidelines (42.8% of reviewed articles), mainly by diagnostic imaging. Conclusions: Research focused explicitly on SID in cancer diagnosis is needed. Moreover, economic, social, and structural reforms related to the factors that connect overuse, overdiagnosis, and unnecessary services to cancer diagnosis are required to control costs and harm and provide the best benefits to patients.

Why clinicians overtest: development of a thematic framework

BACKGROUND

Medical tests provide important information to guide clinical management. Overtesting, however, may cause harm to patients and the healthcare system, including through misdiagnosis, false positives, false negatives and overdiagnosis. Clinicians are ultimately responsible for test requests, and are therefore ideally positioned to prevent overtesting and its unintended consequences. Through this narrative literature review and workshop discussion with experts at the Preventing Overdiagnosis Conference (Sydney, 2019), we aimed to identify and establish a thematic framework of factors that influence clinicians to request non-recommended and unnecessary tests.

METHODS

Articles exploring factors affecting clinician test ordering behaviour were identified through a systematic search of MedLine in April 2019, forward and backward citation searches and content experts. Two authors screened abstract titles and abstracts, and two authors screened full text for inclusion. Identified factors were categorised into a preliminary framework which was subsequently presented at the PODC for iterative development.

RESULTS

The MedLine search yielded 542 articles; 55 were included. Another 10 articles identified by forward-backward citation and content experts were included, resulting in 65 articles in total. Following small group discussion with workshop participants, a revised thematic framework of factors was developed: "Intrapersonal" - fear of malpractice and litigation; clinician knowledge and understanding; intolerance of uncertainty and risk aversion; cognitive biases and experiences; sense of medical obligation "Interpersonal" - pressure from patients and doctor-patient relationship; pressure from colleagues and medical culture; "Environment/context" - guidelines, protocols and policies; financial incentives and ownership of tests; time constraints, physical vulnerabilities and language barriers; availability and ease of access to tests; pre-emptive testing to facilitate subsequent care; contemporary medical practice and new technology CONCLUSION: This thematic framework may raise awareness of overtesting and prompt clinicians to change their test request behaviour. The development of a scale to assess clinician knowledge, attitudes and practices is planned to allow evaluation of clinician-targeted interventions to reduce overtesting.

Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y

BACKGROUND

In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached.

MAIN BODY

There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default.

CONCLUSION

Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.

Incidentally diagnosed cancer and commonly preceding clinical scenarios: a cross-sectional descriptive analysis of English audit data

OBJECTIVES

Cancer can be diagnosed in the absence of tumour-related symptoms, but little is known about the frequency and circumstances preceding such diagnoses which occur outside participation in screening programmes. We aimed to examine incidentally diagnosed cancer among a cohort of cancer patients diagnosed in England.

DESIGN

Cross-sectional study of national primary care audit data on an incident cancer patient population.

SETTING

We analysed free-text information on the presenting features of cancer patients aged 15 or older included in the English National Audit of Cancer Diagnosis in Primary Care (2009-2010). Patients with screen-detected cancers or prostate cancer were excluded. We examined the odds of incidental cancer diagnosis by patient characteristics and cancer site using logistic regression, and described clinical scenarios leading to incidental diagnosis.

RESULTS

Among the studied cancer patient population (n=13 810), 520 (4%) patients were diagnosed incidentally. The odds of incidental cancer diagnosis increased with age (p<0.001), with no difference between men and women after adjustment. Incidental diagnosis was most common among patients with leukaemia (23%), renal (13%) and thyroid cancer (12%), and least common among patients with brain (0.9%), oesophageal (0.5%) and cervical cancer (no cases diagnosed incidentally). Variation in odds of incidental diagnosis by cancer site remained after adjusting for age group and sex.There was a range of clinical scenarios preceding incidental diagnoses in primary or secondary care. These included the monitoring or management of pre-existing conditions, routine testing before or after elective surgery, and the investigation of unrelated acute or new conditions.

CONCLUSIONS

One in 25 patients with cancer in our population-based cohort were diagnosed incidentally, through different mechanisms across primary and secondary care settings. The epidemiological, clinical, psychological and economic implications of this phenomenon merit further investigation.

Improving coding and primary care management for patients with chronic kidney disease: an observational controlled study in East London

BACKGROUND

The UK national chronic kidney disease (CKD) audit in primary care shows diagnostic coding in the electronic health record for CKD averages 70%, with wide practice variation. Coding is associated with improvements to risk factor management; CKD cases coded in primary care have lower rates of unplanned hospital admission.

AIM

To increase diagnostic coding of CKD (stages 3-5) and primary care management, including blood pressure to target and prescription of statins to reduce cardiovascular disease risk.

DESIGN AND SETTING

Controlled, cross-sectional study in four East London clinical commissioning groups (CCGs).

METHOD

Interventions to improve coding formed part of a larger system change to the delivery of renal services in both primary and secondary care in East London. Quarterly anonymised data on CKD coding, blood pressure values, and statin prescriptions were extracted from practice computer systems for 1-year pre- and post-initiation of the intervention.

RESULTS

Three intervention CCGs showed significant coding improvement over a 1 year period following the intervention (regression for post-intervention trend P<0.001). The CCG with highest coding rates increased from 76-90% of CKD cases coded; the lowest coding CCG increased from 52-81%. The comparison CCG showed no change in coding rates. Combined data from all practices in the intervention CCGs showed a significant increase in the proportion of cases with blood pressure achieving target levels (difference in proportion P<0.001) over the 2-year study period. Differences in statin prescribing were not significant.

CONCLUSION

Clinically important improvements to coding and management of CKD in primary care can be achieved by quality improvement interventions that use shared data to track and monitor change supported by practice-based facilitation. Alignment of clinical and CCG priorities and the provision of clinical targets, financial incentives, and educational resource were additional important elements of the intervention.

The when and how of the gynaecological examination: a survey among Norwegian general practitioners

Introduction: Little is known about the indications general practitioners (GPs) perceive as relevant for performing gynaecological examinations (GEs), how GPs master the GE and associated procedures, and how they handle the sensitive nature of GEs. Methods: In 2015, 70 medical students at the University of Bergen distributed a questionnaire to all 175 GPs in the practices they visited. The questions covered practical routines related to GEs, insertion of intrauterine device, frequency of GEs in different clinical settings and use of assisting personnel. Statistical analyses included chi-square tests and multiple logistic regressions adjusting for age, gender, specialization and localization. Results: Ninety male and 61 female GPs (87% of invited GPs) responded to the questionnaire. A minority (8%) usually had other staff present during GEs. Compared with female colleagues, male GPs performed bimanual palpation significantly less often in connection with routine Pap smear (AOR 0.3 (95% CI 0.1-0.6)). Twenty-eight percent of the GPs stated that they often/always omitted the GE if the patient was anxious about GE and 35% when the patient asked for referral to a gynaecologist. Omission was more frequent among male GPs. When the GP decided to refer to a gynaecologist based on the patient's symptoms, more male than female GPs omitted GE (AOR 2.5 (95% CI 1.1-5.4)). Conclusion: Male gender of the GP may be associated with barriers to medical evaluation of pelvic symptoms in women, potentially leading to substandard care. Possibly, however, male GPs' reluctance to perform the GE may also limit unnecessary bimanual palpation in asymptomatic women.

Dilemmas of medical overuse in general practice - A focus group study

OBJECTIVE

To obtain first-hand in-depth accounts of overtesting amongst GPs in Norway, as well as the GPs' perspectives on drivers of overtesting and strategies that can prevent overtesting.

DESIGN AND SETTING

Four focus groups with GPs were conducted. All participants were asked to share examples of unnecessary testing from their everyday general practice, to identify the driving forces involved in these examples and discuss any measures that might prevent excessive testing. All authors collaborated on the analysis, conducted as systematic text condensation, using critical incident technique.

RESULTS

This study reveals two main positions regarding overtesting in general practice. In the categorical position there is no such thing as overtesting and GPs are obliged to perform extensive investigations on the suspicion that any person can carry a fatal disease, no matter how minor or absent their symptoms are. In contrast, in the dilemmatic position, the GPs acknowledge that investigations can cause significant harm, but still feel pressured to discover disease at the earliest opportunity and to meet patients' demands. The GPs' strategies for resolving this dilemma are often demanding and not always successful, but sharing uncertainty and fallibility with patients and colleagues appears to be the most promising strategy.

CONCLUSIONS

Our study indicates that GPs in Norway experience a strong pressure to discover any instance of disease and to meet patients' demands for investigations. One way of preventing the harm that accrues from overtesting is openly sharing uncertainty and fallibility with patients and colleagues.

Rethinking medicine

There’s something going on out there

Inside general practice ethics: guidelines 'and' 'of' or 'for' good clinical practice

The RCGP conference, like other annual healthcare conferences offers a protected space for reflection on ethical aspects of practice. This paper presents a summary and discussion of a fringe session led by the RCGP Committee On Medical Ethics at the 2017 RCGP annual conference in Liverpool. Well thought-out rules offer a potential solution to the burden of responsibility for making every single decision from first principles. But guidelines can be difficult to follow, too numerous to know, may conflict with each-other and may not be appropriate in all circumstances. Delegates at this meeting discussed barriers to good guideline development and implementation, perceptions of medicolegal risk in non-adherence, aspects of benefit, harm and justice in guideline use and ethical guidelines. Delegates found it easier in the meeting to critique clinical rather than ethical guidelines. There was broad agreement that understanding how to practice in relation to guidelines represented a learning need in general practice education.