The challenges of seeking to avoid overdiagnosis and overtreatment: exploring defensive practice
3 Year PhD Studentship available for September 2019
Background: Overdiagnosis and overtreatment are significant problems in contemporary healthcare, with concerns about the possible harms and avoidable waste of ‘too much medicine’.(1) While not necessarily straightforward to define,(2) the terms generally refer to instances in which a diagnosis is ‘correct’ according to current standards but the diagnosis or associated treatment has a low probability of benefitting the patient, and may instead be harmful. Concerns initially focused on cancer screening but now extend to a wide range of clinical activities.(3) The potential consequences may be significant and include such harms as the psychological and behavioural effects of disease labelling, physical harms and side effects of unnecessary tests or treatments, negative effects on quality of life, increased financial costs to individuals, and wasted resources and opportunity costs to the health system.(4) Alongside these potential harms lie those which may arise from ‘too little’ rather than ‘too much’ medicine: “overdiagnosis of the well and undertreatment of the sick are the conjoint twins of modern medicine”.(5) Efforts to tackle overdiagnosis and overtreatment may be complicated by the way in which many attempts to improve care quality encourage doing more rather than less.
There is concern, for example, that guidelines intended to reduce variation and improve care have instead encouraged the neglect of respect for patients’ preferences. Mechanisms for ‘opting out’ are not simple; removing patients from pay-for-performance schemes is complex and how to account within audits for those declining tests or treatments (rather than not being offered them) is not clear. Overdiagnosis and overtreatment can thus be understood as a consequence of the organisational, financial and cultural attributes of the healthcare system.
Project Many potential drivers of overdiagnosis and overtreatment have been identified and professionals’ fears of future litigation and their consequent defensive practice are commonly cited as important, but our understanding of these concerns, their validity, and their consequences for patient care remain remarkably underdeveloped. This project will draw on relevant social science theory around diagnosis, the management of risk and uncertainty, and accountability, governance and regulation to examine a purposive sample of clinical case studies. Using qualitative methods including interviews, observations, and documentary analysis these case studies will explore in detail professionals’ concerns about the potential implications of seeking to do less rather than more for their patients and how features of the way in which the healthcare system is organised and governed make it challenging for clinicians and patients to behave in ways that might be considered ‘deviant’. These accounts will be analysed in the context of UK law on medical negligence and professional ethics.
The project proposed here aligns clearly with Professor Armstrong’s ongoing Health Foundation Improvement Science Fellowship on health system change to mitigate overdiagnosis and overtreatment, and with wider interests in the SAPPHIRE Group on the management of uncertainty related to diagnosis and treatment. This is a multidisciplinary project drawing on strengths from the SAPPHIRE Group and working collaboratively with the medico-legal cluster within Leicester Law School. The joint supervisors between them have expertise in: applying social science theory and methods to healthcare improvement; qualitative methods in applied healthcare research; overdiagnosis and overtreatment; and medical negligence and professional ethics.
Entry requirements Applicants are required to hold/or expect to obtain a UK Bachelor Degree 2:1 or better in a relevant subject. The University of Leicester English language requirements apply where applicable: https://le.ac.uk/study/research-degrees/entry-reqs/eng-lang-reqs
How to apply You should submit your application using our online application system: https://www2.le.ac.uk/research-degrees/phd/applyphd
Apply for a PhD in Health Sciences
In the funding section of the application please indicate you wish to be considered for a CLS Studentship
In the proposal section please provide the name of the supervisor and project you want to be considered for.
Project / Funding Enquiries: Professor Natalie Armstrong
Email: [Email Address Removed]
Telephone: 0116 252 3197
Application enquiries to [Email Address Removed]
Closing date for applications: 31st January 2019
• The University will provide a tuition fee waiver at UK/EU rates for 3 years
• A three year student stipend based on RCUK rates (currently £14,777 for 2018/19)
• Research Training Support Grant (including travel allowance) of £1,300 pa
1. BMJ. Too Much Medicine 2018. http://www.bmj.com/too-much-medicine
2. Carter SM, Rogers W, Heath I, Degeling C, Doust J, Barratt A. The challenge of overdiagnosis begins with its definition. BMJ. 2015;350:h869.
3. Jenniskens K, de Groot JAH, Reitsma JB, Moons KGM, Hooft L, Naaktgeboren CA. Overdiagnosis across medical disciplines: A scoping review. BMJ Open.2017;7(12):e018448-2017-018448.
4. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: How to stop harming the healthy. BMJ. 2012;344:e3502.
5. Heath I. Role of fear in overdiagnosis and overtreatment--an essay by Iona Heath. BMJ. 2014;349:g6123.