The Goldilocks diagnosis is not ‘just right’

There is a nary a day that goes past without some corner of the media lambasting GPs for failing to diagnose. Reading the British newspapers one could reasonably assume that the problem that cripples medicine (or more accurately patients) is one of underdiagnosis. Every GP frets about missed diagnoses but many feel the underlying difficulty with medicine is around overdiagnosis.

Few patients complain about overdiagnosis and it has not picked up much popular traction outside of the profession. Perhaps the closest is the reporting of the escalation in mental health conditions, particularly in young people, where one suspects there remains the whiff of scepticism and a good deal of stigma. Overdiagnosis and underdiagnosis have been conceptualised as a ‘Goldilocks’-type problem, where we need to get the amount of medicine ‘just right’. They are portrayed as two sides of the same coin. Yet, the language here is deceptive. Setting one against the other and the implication that we just need a better balance doesn’t work.

Overdiagnosis is, at its heart, a philosophical approach and one, if it’s not too dramatic, that is wrestling for the soul of medicine. It rails against the relentless medicalisation of people, the ‘pill for any ill’ commercialisation, which is an inevitable consequence of the profit motive. At its worse, it drains the practice of medicine of humanity, reducing us all to profit-cogs in the medico-industrial complex. As Michael J Sandel, the American political philosopher, might highlight, it’s just another moral limit of the market.¹

Not every practitioner who is concerned about overdiagnosis will necessarily agree. They feel in their bones something is awry and the guidelines too often feel like professional handcuffs. For them, overdiagnosis is the diagnosis for what ails medicine. This might be one of the reasons why social prescribing has been embraced with such enthusiasm and, with notable exceptions, a lack of criticality. The evidence remains weak for social prescribing but it is a complex intervention that will need careful unpicking. There is no question that the strongest thing in favour of social prescribing is that it is not actual medication. In many ways, that is important progress, in other ways it is the most lamentable extension of medicalisation.²

Underdiagnosis is, in contrast, a more technocratic challenge. Of course, it is about speaking to patients, and insufficient capacity in the system will have a monstrous impact. We would all be better diagnosticians with fewer patients, more time, and increased continuity. But it is also technical. It’s about the right consultation at the right time, usually with the right test. It’s about picking up the signals in the noise across multiple encounters, repeated bloods, and timely imaging. Diagnosis was once the preserve of doctors but the future will surely involve algorithms — the oh-so subtle drift of platelet counts or inflammatory markers can’t be reliably picked up by us fragile humans. It’s exactly the kind of repetitive task we should be offloading to computers. And, of course, artificial intelligence. This is one balancing act we still need to navigate and will shape medical practice for generations.

Issue highlights

This month we bid farewell to Ahmed Rashid who has written the Yonder column for a decade and pens some final reflections. For a full 10 years, every month, he has brought us pithy summaries from ‘primary care relevant research stories from beyond the mainstream biomedical literature’. He has done us an enormous service, illuminating many areas of practice, and enhancing our understanding of primary care. We are very grateful. In this issue we have editorials on assisted dying and specialist hypertension clinics. Articles on measuring blood pressure, digital rectal examination, and the use of faecal calprotectin should help refine your diagnostic skills.