There is an increasing expectation from players, parents and coaches that we will investigate their problem so that they can understand “exactly what is going on”. This educational review from the BJSM illustrates some of the challenges associated with this approach and outlines the harm that can be associated with ‘overdiagnosis’.1.
The medical community is increasingly concerned that too many people are being ‘overdiagnosed’. In general the term overdiagnosis refers to the identification of deviations, abnormalities, risk factors and pathologies that would never cause symptoms or early death. Overdiagnosis can then lead to ‘overtreatment’ and wasted resources that could be better spent preventing or treating genuine illness. These unnecessary tests, and the treatment that this provokes, can lead to increased morbidity and harm.
Many factors have been identified that might drive overdiagnosis. These include a cultural belief that ‘more is better’, financial incentives, expanding disease definitions and the lowering of treatment thresholds. A good example where overdiagnosis can be a problem in a football medicine setting relates to the use of imaging for many musculoskeletal conditions. It is well known that there is a high incidence of radiological findings in asymptomatic players. Many ‘normal’ players will have hip labral tears, lumbar disc abnormalities or knee chondral injuries on MRI. In the absence of any symptoms or signs these findings are of no clinical relevance and receiving treatment would generally not be appropriate. Unfortunately, once these ‘abnormalities’ have been identified, players (and their parents, trainers or agents) often expect that they are treated. This can lead to confusion, angst and unnecessary treatment (harm).
Choosing Wisely is a campaign that aims to engage doctors and patients in decisions about potentially unnecessary medical tests, treatments and procedures. The initiative encourages medical specialty societies (sport and exercise medicine included) to identify tests and procedures that could potentially be avoided to reduce the harms of too much medicine.
Incidentally orthopaedic surgery has been widely criticised during this campaign for the relatively large number of unnecessary procedures that continue to be performed. For example, there is increasing evidence that many patients do not benefit from knee arthroscopy. Despite this it remains one of the most widely performed orthopaedic procedures.
To be clear this article, as well as the Choosing Wisely campaign, is not asking us to stop investigating or treating our patients. What is suggested however is that we make more considered decisions and that we spend more time trying to articulate this to our patients. When you are making your next treatment plan ask yourself four questions. Do we really need this test, treatment or procedure? What are the downsides? What happens if we do nothing? And are there simpler, safer options?
1.Friedman DJ, Khan KM Preventing overdiagnosis and the harms of too much sport and exercise medicine Br J Sports Med Published Online First: 05 December 2018. doi: 10.1136/bjsports-2018-100039.