현대의학의 오류 : 너무 많이, 너무 경미한, 너무 이른 .. 진단 치료!! 2022

[문형철]

현대의학의 가장 큰 오류는

수많은 과로 쪼개서 가는 곳마다 약물을 투여한다! 

그리고 치료를 주로 약물에 의존하여 너무 많은 약물을 투여한다.

다른 관점으로

너무 일찍 진단을 내리려하고

너무 과잉으로 진단을 내리려하고

과잉으로 대응하려고 한다는 논문!!

Int J Gen Med

. 2022 Aug 6;15:6441–6450. doi: 10.2147/IJGM.S368541

Too Much, Too Mild, Too Early: Diagnosing the Excessive Expansion of Diagnoses

Bjørn Hofmann 1,2,✉

• Author information
• Article notes
• Copyright and License information

PMCID: PMC9365059  PMID: 35966506

Abstract

Tremendous scientific and technological advances have vastly improved diagnostics. At the same time, false alarms, overdiagnosis, medicalization, and overdetection have emerged as pervasive challenges undermining the quality of healthcare and sustainable clinical practice. Despite much attention, there is no clarity on the classification and handling of excessive diagnoses. This article identifies three basic types of excessive diagnosing: too much, too mild, and too early. Correspondingly, it suggests three ways to reduce excess and advance high value care: we must stop diagnosing new phenomena, mild conditions, and early signs that do not give pain, dysfunction, and suffering.

과학적 및 기술적 진보는

진단 기술을 크게 향상시켰습니다.

그러나 동시에

허위 경보, 과진단, 의료화, 과탐지와 같은 만연한 문제들이

의료의 질과 지속 가능한 임상 관행을 저해하는 도전 과제가 되고 있습니다.

false alarms,

overdiagnosis,

medicalization, and

overdetection 

많은 주목을 받았음에도 불구하고

과도한 진단의 분류 및 처리를 위한 명확한 기준은 아직 없습니다.

이 논문은

과도한 진단의 세 가지 기본 유형을 식별합니다:

너무 많이,

너무 경미한,

그리고 너무 이른 진단입니다.

too much,

too mild, and

too early

이에 상응하여 과잉을 줄이고 고가치 의료를 촉진하기 위한

세 가지 방법을 제안합니다:

우리는 고통, 기능 장애, 고통을 유발하지 않는

새로운 현상, 경미한 상태, 그리고 초기 징후에 대한 진단을 중단해야 합니다.

we must stop diagnosing new phenomena, mild conditions, and early signs that do not give pain, dysfunction, and suffering.

Keywords: diagnosis, overdiagnoses, overtreatment, expansion, excess

Introduction

Due to tremendous scientific and technological advances, there have been vast expansions in the number of diagnoses. From John Graunt’s Bills of Mortality in 1665 till ICD-11,1 DSM-5,2 ICPC-2,3 and in ICF4 more people are diagnosed with more diseases than ever before. Figure 1 shows the expansion of number of diagnostic codes from ICD-1 in 1900 till ICD-11 in 2018.

소개

과학 기술의 엄청난 발전으로 진단 건수가 크게 증가했습니다. 1665년 John Graunt의 사망률 보고서부터 ICD-11,1 DSM-5,2 ICPC-2,3 및 ICF4에 이르기까지 그 어느 때보다 더 많은 사람들이 더 많은 질병으로 진단받고 있습니다. 그림 1은 1900년 ICD-1부터 2018년 ICD-11까지 진단 코드의 수의 확대를 보여줍니다.

Figure 1.

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Expansion in the number of diagnoses in the International Classification of Disease (ICD).

Part of this expansion stems from an ample increase in knowledge about bodily, behavioural, and mental mechanisms. By differentiating existing diagnoses in more precise and actionable entities, more people can be helped - better and earlier than ever before.

However, our diagnostic capacities by far outrun our abilities to help. Not only do we lack curative measures for all diagnoses, but the many diagnostic technologies also come with errors,5 and we come to diagnose when it does not help people. While we can detect many more phenomena than ever before, we lack knowledge of whether they represent or predict anything that is clinically relevant, such as pain, dysfunction, and suffering.6 Medicine has expanded its taxonomies from descriptions of experienced and manifest disease to indicators (eg, biomarkers), risk factors (eg, hypertension),7 social phenomena (eg, behaviour), aesthetic phenomena (eg, look), and many non-harmful conditions.

The growth in diagnoses has been described as a “diagnostic inflation”,8–12 “diagnostic expansion”,13–19 and “diagnostic creep”20–23 and has been characterized by concepts, such as medicalization (over-, bio-),24 overdiagnosis,25 overdetection, overdefinition,26 misclassification, maldetection,27 disease mongering28 etc.

While the vast expansion of diagnoses appears to be haunted by complex causes and conceptual confusion, it is embodied by three basic phenomena: too much, too mild, and too early. The first represents an expansion of diagnoses by including new phenomena, the second is an extension by degrees, and the latter is a temporal expansion. Table 1 provides an overview of the three types of excessive expansion of diagnoses.

그러나

우리의 진단 능력은 도움을 제공하는 능력을 훨씬 초과합니다.

모든 진단에 대한 치료법이 부족할 뿐만 아니라,

많은 진단 기술은 오류를 동반하며⁵,

도움이 되지 않는 경우에도 진단을 내리게 됩니다.

이전보다 훨씬 더 많은 현상을 탐지할 수 있지만,

그것이 통증, 기능 장애, 고통과 같은

임상적으로 중요한 것을 나타내거나 예측하는지 여부에 대한 지식은 부족합니다.⁶

의학은 경험되고 명백한 질병에 대한 설명에서

지표(예: 바이오마커), 위험 요인(예: 고혈압)⁷, 사회적 현상(예: 행동), 미적 현상(예: 외모),

그리고 많은 무해한 상태로 분류를 확장했습니다.

진단의 증가는

"진단 인플레이션"⁸⁻¹², "진단 확장"¹³⁻¹⁹, "진단 크립"²⁰⁻²³으로 묘사되었으며,

의료화(과다, 생물학적-),

과진단²⁵, 과탐지, 과정의, 오분류, 부적절 탐지²⁷, 질병 조장²⁸ 등의 개념으로 특징지어졌습니다.

diagnostic inflation”,8–12 “diagnostic expansion”,13–19 and “diagnostic creep”20–23 and has been characterized by concepts, such as medicalization (over-, bio-),24 overdiagnosis,25 overdetection, overdefinition,26 misclassification, maldetection,27 disease mongering

진단의 광범위한 확장은 복잡한 원인과 개념적 혼란에 시달리는 듯 보이지만,

세 가지 기본 현상으로 나타납니다:

너무 많이, 너무 경미한, 그리고 너무 이른 진단입니다.

첫 번째는 새로운 현상을 포함하여 진단의 확장,

두 번째는 정도에 따른 확장,

세 번째는 시간적 확장을 나타냅니다.

표 1은

과도한 진단 확장의 세 가지 유형에 대한 개요를 제공합니다.

Table 1.

Overview of the Three Types of Excessive Expansion of Diagnoses: Too Much, Too Mild, and Too Early

Too MuchToo MildToo Early

Type of expansion	Including New Phenomena	Expansion by Degrees	Temporal Expansion
Description	Including (labelling) new phenomena a) ordinary life experiences b) social phenomena c) biomedical phenomena	Lowering the detection threshold including milder cases in the definition of the disease that do not bother the person (here and now)	Diagnosing abnormalities not going to cause harm by disease (pain, dysfunction, suffering) in the future
Ley explanation	Ordinary life conditions (potentially better dealt with by others or left alone) or irrelevant biological or mental phenomena are labelled as diagnoses	Conditions you live with without being bothered by them	Conditions that would not come to bother you, ie, conditions that you die with and not from.
Class of expansion	Ontological	Normative-Conceptual	Epistemic-Temporal
Main problem	Wrong treatment, potential harm from unnecessary or wrong treatment; divert from more efficient measures; digress responsibility; anxiety, stigma, discrimination	Unnecessary treatment, potential harm from diagnostics and unnecessary treatment	Overtreatment, potential harm from overdiagnosis and overtreatment
Example	a) Loneliness, grief b) School behavior (ADHD) c) Obesity, various risk factors, such as high blood glucose	Gestational diabetes, chronic kidney disease	Precursors of disease that do not develop into disease
Terminology	Medicalization Maldetection, Overdetection	Misclassification, Overdefinition	Overdiagnosis
Concept creep	Horisontal expansion	Vertical expansion	NA

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Before scrutinizing these three types of expansion of diagnoses, it is important to acknowledge the manifold function of diagnoses and their complex role in medicine and in society at large. For health professionals, diagnoses are crucial for forming a conceptual framework, to coordinate communication, and to guide actions.29 For the health care system, they are key for the organization of activities, institutions, and departments. For society diagnoses are fundamental to ensure justice, as diagnoses are used to attribute rights (to care) and free from obligations (work) as well as attributing accountability (eg, with respect to legal (in)sanity). For patients diagnoses are essential to understand one’s situation, adjust one’s aspirations, explain the situation to others, and to get access to attention, treatment, and care from health professionals.29 Hence, diagnoses involve a range of norms and values for a wide variety of stakeholders in great many contexts. Accordingly, they do very much good for individuals, professionals, and for societies at large. In this article, however, I focus on the less good aspects of expanding diagnoses. The aim is to enhance the good side of diagnoses (expansion) by avoiding the bad ones, ie, to improve the health care in one of its crucial activities for helping individuals: diagnostics.

이 세 가지 진단 확장 유형을 면밀히 검토하기 전에,

진단의 다양한 기능과 의학 및 사회 전반에서

그 복잡한 역할을 인정하는 것이 중요합니다.

건강 전문가에게 진단은

개념적 틀을 형성하고,

의사소통을 조율하며,

행동을 안내하는 데 필수적입니다.²⁹

건강 관리 시스템에서는

활동, 기관, 부서의 조직화에 핵심 역할을 합니다.

사회에서는 정의를 보장하기 위해 진단이 중요하며,

진단은 권리(치료에 대한)를 부여하고

의무(일)에서 해방시키며 책임을 부여(예: 법적 (비)정신 상태)합니다.

환자에게 진단은

자신의 상황을 이해하고, 목표를 조정하며, 다른 사람에게 상황을 설명하고,

건강 전문가로부터 주의, 치료, 간호를 받는 데 필수적입니다.²⁹

따라서

진단은 다양한 이해관계자와 맥락에서 다양한 규범과 가치를 포함합니다.

이에 따라 개인, 전문가, 사회 전체에 많은 이점을 제공합니다.

그러나 이 논문에서는 진단 확장의 덜 좋은 측면에 초점을 맞춥니다.

목표는

진단의 좋은 면(확장)을 개선하고 나쁜 면을 피함으로써 개인을 돕는 데 핵

심적인 활동인 진단을 통해 의료를 향상시키는 것입니다.

Three Types of Excess: Too Much, Too Mild, and Too Early Diagnosis

In the case of too much diagnosis we tend to label phenomena that have not been diagnosed before. This can be a) ordinary life experiences, such as loneliness or grief, b) social phenomena, such as school behavior in children (ADHD)45 or c) biomedical phenomena, such as elevated blood pressure, obesity or measurable risk factors. While expanding diagnoses by including new phenomena can be warranted and welcome, it does not always benefit the persons and can be harmful, ie, it is too much. Certainly, it can be difficult to decide what is beneficial and what is harmful, and there may be different perspectives on the benefit-to-harm balance amongst patients, proxies, patient organizations, professionals, and health policy makers. Nevertheless, we need to focus on when we get too much diagnosis.

Diagnoses may also be unduly expanded by lowering the detection threshold beyond what benefits the person, ie, being too mild. By including milder cases in the definition of the disease or in its diagnostic criteria, people can be diagnosed with diseases that may not bother them. Gestational diabetes and chronic kidney disease may serve as examples.30 While detecting and treating milder cases may appear successful, many of the subsequent treatments may not benefit the persons. They would have lived with the condition without experiencing it.

Excessive expansion of diagnoses may also occur by diagnosing too early, ie, by temporal expansion. This happens when we diagnose abnormalities that are not going to cause harm by disease (in terms of pain, dysfunction, suffering) in the future. This can be precursors of disease that do not develop into disease, such as cases of ductal carcinoma in situ (DCIS) or indolent lesion of epithelial origin (IDLE).31

Figure 2 illustrates how diagnoses can be too mild and too early related to wellbeing and suffering over time.

세 가지 과잉 유형: 너무 많이, 너무 경미한, 그리고 너무 이른 진단

"너무 많이" 진단하는 경우,

이전에 진단되지 않았던 현상을 라벨링하는 경향이 있습니다.

이는

a) 외로움이나 슬픔과 같은 일상 경험,

b) ADHD와 같은 아동의 학교 행동과 같은 사회적 현상,

c) 고혈압, 비만, 측정 가능한 위험 요인과 같은 생물의학적 현상일 수 있습니다.

새로운 현상을 포함하여 진단을 확장하는 것은 정당화되고 환영받을 수 있지만,

항상 개인에게 이익이 되지 않으며 해로울 수 있습니다,

즉 "너무 많이"입니다.

물론 무엇이 이롭고 무엇이 해로운지 결정하기는 어렵고,

환자, 대리인, 환자 단체, 전문가, 건강 정책 입안자들 사이에서

이익-해로움 균형에 대한 관점이 다를 수 있습니다.

그럼에도 불구하고

우리는 언제 "너무 많이" 진단하는지에 초점을 맞춰야 합니다.

진단은

또한 개인에게 이익이 되지 않는 범위 이상으로 탐지 임계값을 낮춤으로써

부당하게 확장될 수 있습니다,

즉 "너무 경미한" 경우입니다.

질병의 정의나 진단 기준에 더 경미한 사례를 포함함으로써,

사람들에게 방해가 되지 않을 수 있는 질병으로 진단될 수 있습니다.

임신성 당뇨병과 만성 신장 질환이 예로 들 수 있습니다.³⁰

경미한 사례를 탐지하고 치료하는 것은 성공적으로 보일 수 있지만, 후속 치료의 대부분은 개인에게 이익이 되지 않을 수 있습니다. 그들은 그 상태를 경험하지 않고도 살아갔을 것입니다.

진단의 과도한 확장은

또한 "너무 이른" 진단,

즉 시간적 확장으로 발생할 수 있습니다.

이는 미래에 질병(통증, 기능 장애, 고통 측면)으로 해를 끼치지 않을 이상을 진단할 때 발생합니다.

이는 질병으로 발전하지 않는 질병의 전구체,

예를 들어 관상관상피내암(DCIS) 또는 비활성 상피 기원 병변(IDLE) 사례일 수 있습니다.³¹

그림 2는 시간이 지남에 따라 웰빙과 고통과 관련된

"너무 경미한" 및 "너무 이른" 진단을 보여줍니다.

Figure 2.

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Too mild and too early diagnoses in terms of wellbeing and suffering over time. The four lines indicate four different life trajectories: Too early (red), too mild (Orange), too late (blue) and appropriate (green). The trajectories are of cases without medical interaction.

Why is It Bad?

The problems with the three types of expansion are somewhat different. In the case of too much diagnosis we can digress responsibility and divert from more efficient measures, eg, when we make ordinary life experiences, such as grief and loneliness, or social phenomena, such as school behavior, diagnoses. Some such phenomena may be better dealt with outside the healthcare system, eg, by families and friends.

Moreover, we may also do too much diagnosing of biomedical phenomena when they are not experienced in terms of pain, dysfunction, or suffering. Mild hypertension or hyperglycemia, or various risk factors, such as obesity, are most often not experienced as painful or dysfunctional, but treating them can introduce potential harms from diagnostics and treatment. Headache, dizziness, constipation, diarrhea, muscle pain, fatigue, sleep problems, and low blood platelet count from statin use is but one example of the latter. Moreover, getting a diagnosis can reduce the quality of life and cause anxiety and stigma.29,32

In sum, we can do wrong when we diagnose too much when applying inappropriate labels and treatments, when diverting from more efficient measures, and when inciting harms from diagnostics and treatment.

In the case of too mild diagnosis, we inflate diagnosis by including phenomena that are too mild to cause any pain, dysfunction, or suffering or where the treatment results in more harm than benefit. In such cases we provide unnecessary treatment and introduce potential harm both from diagnostics and treatment.

Too early diagnosis results in overdiagnosis and overtreatment and potential harm from both. The cases that we detect and treat, would never have caused the person any problems. Hence, we violate the ethical principles of non-maleficence and beneficence. Additionally, we drain resources from alternative health care services (justice) and patients do not know that they are overdiagnosed and overtreated (autonomy). The problem is that it is (yet) difficult to predict whether a detected condition will develop into something that causes pain, dysfunction, or suffering.33

Basic Differences and Overlaps Between the Types of Diagnostic Expansion

Too much, too mild, and too early represent different types of unwarranted expansion of diagnoses. The first is an expansion of phenomena in the world to be included in diagnoses. This is an ontological expansion. This corresponds to what has been called a “horizontal expansion” in the framework of concept creep, as more cases are included “horizontally”.20

In the case of too mild diagnosis, we lower the detection threshold value so that milder cases are included. In doing so we change the norms that decide which cases fall under the concept of a particular diagnosis. Thus, this is a normative-conceptual expansion, and resembles “vertical expansion” in concept creep, as milder cases are included.20

In the case of too early diagnosis, we detect and treat conditions that we do not know whether will develop into disease and cause pain, dysfunction, and suffering in the future. Accordingly, this is an expansion into the unknown future, ie, an epistemic-temporal expansion.33

What can cause confusion is the fact that we have combinations of these expansions. For example, we can diagnose biomedical phenomena that are not experienced, and which will not develop to experienced disease in the future, such as various precursors of disease. Then we detect too much and too early.

Correspondingly, we can diagnose mild conditions that will not develop to experienced disease in the future, like in the case with hypertension or hyperglycemia. Such expansions are too mild and too early. Notably, they are both overdetection, as they detect mild cases that do not bother the person here and now, and overdiagnosis, as they may not cause any problems to the person in the future.

The important difference between too mild and too early diagnosis is whether the disease is occurring here and now or in the future. Figure 3 illustrates cases of too much, too mild, and too early diagnoses.

왜 문제인가?

세 가지 확장 유형의 문제는 다소 다릅니다.

"너무 많이" 진단하는 경우, 책임을 회피하고 더 효율적인 조치에서 벗어날 수 있습니다.

예를 들어, 슬픔과 외로움과 같은 일상 경험이나 학교 행동과 같은 사회적 현상을 진단으로 만들 때입니다.

이러한 현상 중 일부는 의료 시스템 외부, 예를 들어 가족과 친구들에 의해 더 잘 다뤄질 수 있습니다.

또한, 통증, 기능 장애, 또는 고통으로 경험되지 않는 생물의학적 현상을

"너무 많이" 진단할 수도 있습니다.

경미한 고혈압이나 고혈당, 비만과 같은

다양한 위험 요인은 대부분 통증이나 기능 장애로 경험되지 않지만,

이를 치료하면 진단과 치료에서 잠재적 해로움을 초래할 수 있습니다.

스타틴 사용으로 인한

두통, 어지럼증, 변비, 설사, 근육통, 피로, 수면 문제, 낮은 혈소판 수는

후자의 한 예입니다.

또한, 진단을 받으면 삶의 질이 저하되고 불안과 낙인이 생길 수 있습니다.²⁹,³²

요컨대, 부적절한 라벨과 치료를 적용하고,

더 효율적인 조치에서 벗어나며,

진단과 치료에서 해로움을 유발할 때 "너무 많이" 진단하는 것은 잘못된 것입니다.

"너무 경미한" 진단의 경우,

통증, 기능 장애, 고통을 일으키지 않거나 치료가 이익보다 더 많은 해로움을 초래하는 현상을 포함하여

진단을 부풀립니다.

이러한 경우 불필요한 치료를 제공하고

진단 및 치료에서 잠재적 해로움을 초래합니다.

"너무 이른" 진단은 과진단과 과다 치료를 초래하며,

둘 다에서 잠재적 해로움을 유발합니다.

우리가 탐지하고 치료하는 사례는

결코 개인에게 문제를 일으키지 않았을 것입니다.

따라서 우리는 비(非)해충 및 수혜의 윤리적 원칙을 위반합니다.

또한, 대안적인 의료 서비스에서 자원을 소진시키며(정의),

환자는 자신이 과진단 및 과다 치료를 받고 있음을 알지 못합니다(자율성).

문제는 탐지된 상태가 미래에 통증, 기능 장애, 고통을 일으킬지 예측하는 것이(아직) 어렵다는 점입니다.³³

Figure 3.

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Illustration of cases where there would have been too much, too mild, and too early diagnosis compoared to a case where early diagnosis would have been appropriate.

Too Many Diagnoses

Too much, too mild, and too early are three roads to diagnostic inflation and too many diagnoses. For example, changing the definition of osteoporosis from bone mineral density T-score cut-off to National Osteoporosis Foundation 2008 guideline, the preval‎ence increased from 21% to 72% in US women >65 years.34 Altering the definition of prediabetes from impaired fasting glucose to the American Diabetes Association 2010 criteria increased the preval‎ence from 26% to 50% in Chinese adults >18 years.34

There are of course also other sources of too many diagnoses. False positive test results can result in wrong diagnoses. Incidental findings of uncertain significance can be either too much or too mild, if they are of inexperienced or irrelevant phenomena, or too early if they will not develop into something experienced. Hence, there are many roads to excess, and differentiating between them is crucial for addressing their problems. Figure 4 illustrates the relationship between the three types of diagnoses expansion.

진단 확장 유형 간의 기본 차이점 및 중복

"너무 많이", "너무 경미한", "너무 이른"은 진단의 부당한 확장의 서로 다른 유형을 나타냅니다. 첫 번째는 진단에 포함될 세계의 현상의 확장입니다. 이는 존재론적 확장입니다. 이는 개념 크립 프레임워크에서 "수평적 확장"에 해당하며, 더 많은 사례가 "수평적으로" 포함됩니다.²⁰

"너무 경미한" 진단의 경우, 탐지 임계값을 낮추어 더 경미한 사례를 포함합니다. 이를 통해 특정 진단 개념에 해당하는 사례를 결정하는 규범을 변경합니다. 따라서 이는 규범-개념적 확장이며, 개념 크립에서 "수직적 확장"과 유사하며, 더 경미한 사례가 포함됩니다.²⁰

"너무 이른" 진단의 경우, 질병으로 발전하여 미래에 통증, 기능 장애, 고통을 일으킬지 알 수 없는 상태를 탐지하고 치료합니다. 따라서 이는 미지의 미래로의 확장, 즉 인식-시간적 확장입니다.³³

혼란을 일으킬 수 있는 것은 이러한 확장의 조합이 존재한다는 사실입니다. 예를 들어, 통증이나 기능 장애로 경험되지 않으며 미래에 경험 질병으로 발전하지 않을 생물의학적 현상, 예를 들어 다양한 질병 전구체를 진단할 수 있습니다. 그러면 우리는 "너무 많이" 그리고 "너무 이른"을 탐지합니다.

마찬가지로, 미래에 경험 질병으로 발전하지 않을 경미한 상태, 예를 들어 고혈압이나 고혈당의 경우를 진단할 수 있습니다. 이러한 확장은 "너무 경미한" 그리고 "너무 이른"입니다. 주목할 만하게도, 이는 현재 여기서 당장 사람을 괴롭히지 않는 경미한 사례를 탐지하므로 과탐지이며, 미래에 사람에게 문제를 일으키지 않을 수 있으므로 과진단입니다.

"너무 경미한"과 "너무 이른" 진단의 중요한 차이점은 질병이 현재 여기서 발생하는지 또는 미래에 발생하는지에 있습니다. 그림 3은 "너무 많이", "너무 경미한", "너무 이른" 진단의 사례를 보여줍니다.

Figure 4.

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Illustration of the relationship between the three types of diagnoses expansion including other diagnostic errors.

Maldetection, Misclassification, Overdetection, and Overdefinition

The many attempts to address the multiple ways that diagnoses can expand excessively have created a wide range of specific concepts, and created some confusion, for example between concepts, such as maldetection, misclassification, overdetection, and overdefinition. Diagnosing “abnormalities” that are not going to cause harm, have been called “maldetection overdiagnosis”27 and “overdetection overdiagnosis”.35 These are cases of too early diagnosis. Moreover, diagnosing too mild cases has been called “misclassification overdiagnosis”27 and “overdefinition overdiagnosis”.35 However, the latter includes risk factors, which is a case of including too much. Others have counted maldetection and misclassification out of overdiagnosis and consider them to be causes of overdiagnosis.25

Hence, there is little agreement on the conceptual framework for addressing too many diagnoses. Focusing on the basic phenomena too much, too mild, and too early can make it easier to identify and address the basic problems with excessive diagnoses. Furthermore, it can make it simpler to acknowledge what they have in common: they do not help professionals in reducing pain, dysfunction, and suffering in individual persons because they address the wrong phenomena, too mild conditions, and/or diagnose too early.

Targeting Too Many Diagnoses

The analysis of the three types of diagnostic inflation provides directions for targeting their problems.

In order to avoid too much diagnosis, we must prevent labelling phenomena that cannot be clearly connected to human pain, dysfunction, or suffering with medical diagnostic labels as labelling can have a wide range of negative effects.36 Hence, we may do more harm than good. Moreover, we must be careful with applying medical labels where medical means are not helpful compared to other approaches. That is not to say that labelling is bad. As pointed out, medical labelling is conceptually and practically essential to medicine. However, medical labelling is directed at helping people, and if our labelling goes beyond what can be connected to pain, dysfunction, or suffering, there is a danger of overdoing. Correspondingly, medically detectable pain, dysfunction, or suffering may be better managed by non-medical means (however they are defined). In such cases we need to reflect on why we need medical instead of non-medical categories, as they can do more harm than good.36

Correspondingly, we must stop diagnosing conditions that are too mild to be of any relevance in terms of reducing pain, dysfunction, or suffering. The point is not to abandon all preventive measures, but only that we must avoid lowering diagnostic thresholds beyond what is helpful to persons. Moreover, we need to inform people well when we are uncertain about who will be helped. Certainly, when we know or have good reasons to believe that a specific condition will aggravate to something that will cause pain, dysfunction, or suffering, we should target the condition as early and as efficiently as possible (carefully balancing the potential risks against the benefits, of course).

Likewise, we must avoid detecting abnormal conditions too early, ie, when it is not helpful in avoiding experienced disease. Clearly, it can be very valuable to detect abnormal conditions early, but we should refrain from doing so when it does not avoid or reduce the burden of disease. This is certainly no easy task, but the task should not be evaded.

Moreover, we must have open discussions on the trade-offs between too early and too late and between too mild and too early. In particular, we should provide evidence to facilitate individual informed choice.

There are many measures to avoid unwarranted expansion of diagnoses. Table 2 provides an overview and indicates how the various measures address the three types of excessive diagnose expansion.

Table 2.

Measures to Avoid Unwarranted Expansion of Diagnoses with Indications of Which Type of Expansion They Address. Darker Shading Indicates That the Measure Addresses the Expansion Better

General Measures (ex ante)	Too Much	Too Mild	Too Early
Health Technology Assessment (HTA)
Using checklists when expanding definition of diseases34
Campaigns (Choosing Wisely, Too Much Medicine, Do Not Do)
Individually oriented measures (ex post)
Dediagnosing – “the removal of diagnoses that do not contribute to reducing the person’s suffering”42
Diagnosis Review – “a review carried out by a family doctor for persons with multiple morbidities to reduce unneeded labels and treatments”30
Avoiding inappropriate imaging and nonindicated diagnostics, by “sticking to acknowledged appropriateness criteria”43
ERASE – undiagnosing in the elderly: “Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines”44

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There are of course other related measures that are relevant for reducing overactivity in health care, such as deprescribing,37 deimplementation,38 decommissioning,39 disinvestment40,41 that are helpful in avoiding too much diagnoses. However, they do not address the other kinds of excessive diagnoses in any particular way.

Appropriate Expansion of Diagnoses

As pointed out in the introduction, diagnoses have many important functions and expanding them can benefit patients, proxies, health professionals, health services managers, and society in many ways. These aspects are well covered in the general literature. The objective in this article has been to address the cases where the expansion of diagnoses is not appropriate. The goal hereby has not been to undermine or downplay the very good aspects of diagnoses and their expansion. On the contrary, it has been to avoid its side-effects, to foster patient safety (by reduced unwarranted diagnoses) and autonomy (by making them better informed), to promote professional integrity (by improving diagnostic competencies), and to maintain trust in medicine and healthcare. In sum, reducing unwarranted expansion of diagnoses is crucial for improving the health care in one of its crucial activities in helping individuals: diagnostics.

Conclusion

There are three types of excessive diagnosing: too much, too mild, and too early. They can result in overdiagnosis and overtreatment, harms from diagnostics and unnecessary treatment, anxiety and stigma, as well as diversion from more efficient measures and responsibilities. To halt excessive diagnosing, we must stop diagnosing a) phenomena, b) mild conditions, and c) early signs that do not give pain, dysfunction, and/or suffering. When faced with uncertainty of risks and benefits of diagnosing, or when trading off between present risks and future benefits, we need to provide good evidence and inform potential beneficiaries. To further high-quality care and sustainable clinical practice we must bar the unwarranted expansion of diagnoses.

Funding Statement

Part of the study is funded by the Norwegian Research Council: Grant number 302503 (IROS).

Key Points

• Excessive diagnosing hampers the advancement of high value care and sustainable clinical practice

• Excessive diagnosing can result in overdiagnosis and overtreatment, harms from unnecessary diagnostics and treatment, medicalization, anxiety, and stigma, as well as diversion from more efficient measures and responsibilities

• To avoid conceptual confusion, we need to address three generic types of excessive diagnosis:

  1. too much: including too many phenomena

  2. too mild: setting the thresholds too low

  3. too early: including conditions that will never bother the person

     ● To stop excessive diagnosing and advance high value care we must stop diagnosing a) phenomena, b) mild conditions, and c) early signs that do not give pain, dysfunction, and suffering

Author Contributions

I am the sole author of this manuscript. I have made all contributions to the work reported, both is in the conception, study design, execution, acquisition of data, analysis and interpretation; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

I certify that there is no conflict of interest in relation to this manuscript, and there are no financial arrangements or arrangements with respect to the content of this manuscript with any companies or organizations.

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