At the Preventing Overdiagnosis Conference in Copenhagen last week, I joined nearly four hundred like-minded family and subspecialist physicians, health professionals, and researchers who are concerned about reducing the harms to patients of widening disease definitions and resulting overdiagnosis and overtreatment. After the American Board of Internal Medicine Foundation's discontinuation of logistical support for the Choosing Wisely campaign and the retirement of JAMA Internal Medicine editor and "Less Is More" champion Rita Redberg (who also attended the conference), it was reassuring to hear that the vital work of doing less to patients and more for them will go on. In addition, the international composition of conference attendees allowed me to learn more about different medical practices in Europe and around the world. Although overuse isn't the only reason that the U.S. spends by far the most per capita of any nation on health care, it does play an important role.
In Germany, where family doctors have an average of just 9 minutes (!) per patient consultation, the German College of General Practice and Family Medicine nonetheless found time to develop a prioritized guideline on “Protection against the overuse and underuse of health care.” Although we have a little more time per patient in the U.S., much of this extra time is spent administering standardized questionnaires to screen for depression and anxiety, a practice that doesn't occur in Canada or the United Kingdom and may, despite the U.S. Preventive Service's Task Force (USPSTF)'s endorsement, lead to more harm (opportunity costs and overdiagnosis) than good.Another area where the U.S. and Canada differ is screening for osteoporosis in primary care. While the USPSTF recommends that all women aged 65 years and older undergo bone measurement testing for osteoporosis (a disease-oriented outcome), the Canadian Task Force on Preventive Health Care recommends “risk assessment–first” screening for prevention of fragility fractures (a patient-oriented outcome) in the same age group, and recommends against screening younger women or men at any age. Not only is the Canadian approach more efficient than universal screening, Roland Grad and colleagues have determined that it requires less clinician time. When there isn't nearly enough time for prevention in primary care, argued Sweden's Minna Johansson and the Mayo Clinic's Victor Montori, guidelines should consider clinicians' time needed to treat.
How much time do Danish general practitioners spend discussing various colorectal cancer screening options? None! In the U.S., a substantial part of every health maintenance visit with a patient aged 50 years (or, perhaps, 45) or older is devoted to having an individual shared decision making discussion about the pros and cons of fecal immunochemical testing (FIT), fecal DNA and FIT co-testing, and screening colonoscopy, then either ordering their preferred test or documenting that they declined to be screened. In Denmark, the public health system identifies age-eligible patients and sends them a FIT test in the mail every 2 years. As a result, the COVID-19 pandemic had only modest effects on Danish adults' participation in colorectal screening and adherence to colonoscopy following a positive test. In the U.S., many practices and health systems are still catching up on the backlog.
Although Americans supposedly value choice in health care, our non-system restricts choice at every turn, through narrow preferred provider networks, limited drug formularies, and the bane of every U.S. family physician's existence: prior authorization. Sometimes it seems that the only area where my patients have choices is cancer screening; male patients of a certain age can even choose to have a PSA test, even though most of the world has rightly concluded that the harms of prostate cancer screening outweigh any benefits. And look out for the multicancer early detection blood tests in development; even though these tests have no proven health benefits and will almost certainly increase false positives and overdiagnosis, no doubt Americans will be among the first to embrace them. There is such a thing as having too many cancer screening choices, if most of them are bad.
