BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
Page 1 of 7
Analysis
ANALYSIS Too much technology Our abilities to produce and use technologies appear to outrun our abilities to reflect on their application. To avoid becoming technological titans and ethical Lilliputians, Bjørn Morten Hofmann argues we need a more reflective and responsible implementation of health technology Bjørn Morten Hofmann researcher
123
University College of Gjøvik, PO Box 1, N-2802 Gjøvik, Norway; 2Centre for Medical Ethics, University of Oslo, Oslo, Norway; 3Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA 1
Medical excess has been recognised as a key problem in modern healthcare.1-9 Overdiagnosis and overtreatment have been identified in a wide range of diseases,4 10 and medicalisation of ordinary human conditions has been heavily criticised.11 12 We seem to do too much of a good thing. Technology tends to have a crucial role in our propensity to excess.
From the invention of the stethoscope in Paris in 1816 to the whole genome sequencing of fetal cell-free DNA in a pregnant woman’s blood, technology has been a transforming factor in medicine. Technology has played a key part in moving medicine from the 2400 disease entities described in Sauvages’ 1793 Nosologica methodica to ICD-10 with more than 40 000 entries. Medical technology has also been a driving force in the growth of expenditure on health.13-15 It by far outweighs other price driving factors, such as an ageing population, increased public demand, income growth, raising prices, and reduced organisational efficiency. Half of the increase in the overall costs in healthcare are attributed to technology.16 Having a new technology raises the clout of hospitals and specialists and spurs a technological arms race.17 Technology is used beyond its benefit and sometimes even when it is harmful.18 No doubt, medical technology is a cornerstone in reducing ailment and improving health. Nevertheless, we need to address the challenges when the tool for improving health makes us diseased and when our means become our ends. Below I identify and analyse the mechanisms and the drivers behind using technology beyond its benefit and suggest measures to handle technology in a reflective and responsible manner.
Self perpetuating loop of diagnostics
The pervasive use of technology in healthcare is driven by a positive feedback loop in clinical diagnostics (fig 1⇓). The expansion of diagnostic technology often starts with a technical improvement—for example, increased spatial resolution of a diagnostic ultrasound machine. Such advances in technical performance may not result in better diagnostics—we may only see better what we already know.19 But sometimes they result in increased accuracy, in terms of improved sensitivity and
specificity.19 A shift from ventilation perfusion scintigraphy to computed tomography pulmonary angiography increases the accuracy in diagnosing pulmonary emboli, revealing more cases of pulmonary embolism.20 This is perceived as a success, which results in closer scrutiny of the images and more frequent testing, leading to detection of milder cases21 and a higher diagnostic yield.22 Computed tomography pulmonary angiography increased the detection of pulmonary embolism by 80% from 1998 to 2006.5 Hence, the technological improvement uncovers a hitherto “under-detected” health problem.1 5 This increases the notion of success and the interest in diagnostic technologies. Correspondingly, the increased number of diseased people spurs therapeutic attention. We start treating people who were previously not treated.18 Hence, ever milder cases are treated, as well as cases that would otherwise not have been detected. Computed tomography, magnetic resonance imaging (MRI), and ultrasound guided aspiration of thyroid nodules, for example, have increased the detection (and removal) of small papillary cancers.1 Treating milder cases improves outcomes, enhancing the impression of success, which in turn boosts technological innovation.18 Table 1⇓ gives some other examples where technology has changed the prevalence of disease.
The profession and society seek technology The pervasive use of technology in healthcare has many drivers (table 2⇓). At the systems level, the supply of technology drives demand.34 35 If an MRI scanner is available it is used. The same goes for blood tests and surgery.35 Technologies are widely used without evidence of their effectiveness, safety, and efficiency18 35-38 and sometimes even though there is evidence that they are not efficient—for example, pulse oximetry for perioperative monitoring and robot surgery.39 40 Occasionally technologies are used even when we know they are harmful.18 We are more eager to invest in new technology with little evidence than to disinvest in technology with evidence for little or no effectiveness.41 42
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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ANALYSIS
Moreover, high tech is associated with high importance43 and high quality.44 Technology is used strategically to attract specialists and patients44 and impels a technological arms race.17 If your competitor has handheld ultrasound machines or a 3T MRI machine, you need to have them as well. Technology transforms from being instrumental to improving health to become a means of power and prestige, or even an end in itself.45 Professionals associate advanced technology with higher prestige both of diseases and specialties.46 Such perspectives are shared by patients, public, and the media, who request high tech interventions. Accordingly, general social myths drive the belief in technology. We believe that the new is better than the old, that the advanced is better than the simple, that more is better than little, that to know is better than not to know, and that to detect early is better than later. If doctors do not order a test, CT, or MRI people think they do not care. This is reinforced by the media. Angry or sad people who did not get the technology they should have hit the headlines, but those who have been overdiagnosed or overtreated are happy to have been “saved.” Additionally, it has been argued that one of the major drivers is technology itself: there is a technological imperative,47 pushing technological innovation beyond healthcare needs, where technology defines diseases and provides the cures.11 48 This technology push has been explained by technology’s compensation for human deficiencies49 and as technology being autonomous.50 Technology has become an independent and powerful actor driving healthcare beyond its original goals. However, such (deterministic) views make us serfs of technology and reduce our responsibility. Paradoxically, we become servants of the technology we design, produce, implement, and use.51 The self perpetuating loop of diagnostic technologies and the identified drivers are helpful in understanding and addressing the pervasive role of technology in healthcare. However, they miss a basic bond between medicine and technology: how technology constitutes our conception of disease.
Technological construction of disease Technology is changing the meaning of disease.52 53 More specifically, technology changes our conception of disease at three levels.54 Firstly, it provides the entities that define disease. Technology such as biochemical analysers, cytometers, and DNA sequencers provides access to enzymes, T cells, or specific strands of DNA. Hence, the core elements of diseases we find in definitions in medical textbooks are constituted by technology. Secondly, it is directing and structuring our knowledge of disease. One day our knowledge of myocardial infarction is based on the electrical activity in the heart measured by electrocardiography, the next it is more based on measurement of troponin in the blood. Thirdly, disease is constituted by technology through practice. If we can measure or manipulate something, it tends to become a disease—for example, hypertension and cholesterolaemia would not be relevant to medicine if we could not measure or manipulate blood pressure or cholesterol. Hence, the expansion of technology profoundly extends our conception of disease—for good and for bad.
Implications of pervasive technology Fig 2⇓ shows some of the implications of the self perpetuating loop of diagnostic technology that are supported by the many
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drivers of technology and the technological constitution of disease. These include: Enhanced leaps of belief—The apparent success of diagnosing and treating more results in unwarranted enthusiasm among professionals and industry, hyped beliefs and demands among patients and the media, as well as unrealistic expectations among policy makers. Benefits seem self evident while downsides are veiled or ignored Good tests become poor—A more accurate diagnostic test may result in poorer outcome if the test is used for ever healthier people. If a diagnostic test increases its sensitivity and specificity from 0.80 to 0.95, the chance that a given positive test result is correct decreases from 0.8 to 0.16 if the prevalence decreases from 1 in 2 to 1 in 100. Hence, technical improvements do not guarantee clinical improvements Detecting more does not help people—Detection of cases does not mean that more patients are treated or that more lives are saved.1 55 56 Instead, more people become diseased, as disease categories are widened or everyday conditions become recategorised as disease. Technical improvements make us detect cases that would otherwise not have caused symptoms or death—that is, overdiagnosis— which subsequently leads to overtreatment.10 57 58 Hence, our technological endeavours to help become futile or even harmful Increased activity—Intensified diagnostic activity generates incidental findings. While some “incidentalomas” save lives, many do not—for example, incidental detection of thyroid cancer with CT or MRI does not reduce symptoms or death.1 Follow-up of diagnostic findings produces other incidental findings. Hence, we do more but less with measurable outcomes for people’s health Increased health anxiety—The raised disease prevalence and increased awareness of health problems make people more concerned and anxious about their health, spurring even more testing and treatment Increased cost—The increase in screening programmes, diagnostic tests, incidental findings, and follow-up substantially raises health expenditure.13-15 This drains resources from areas where technology is really effective and innovations are really needed Reduced value—When the predictive value of diagnostic tests is low, more people are overdiagnosed and overtreated, and people with social or other problems are given medical labels, the usefulness of healthcare endeavours is deflated Undermining trust—With increased awareness of excessive healthcare,7 9 53 low value healthcare,59 60 and “not to do” health services,61 people may lose trust—the cornerstone of healthcare provision.
What we can do? Uncritical implementation and use of technology excites excessive medicine. One reason for this is that technology is deeply ingrained in our conception of disease and our culture. It spurs a series of leaps of faith. Therefore, the first thing we have to do is to get rid of truisms, such as that more is better than less, new is better than old, and advanced is more accurate than simple. We must also acknowledge our responsibility for the development, implementation, and use of medical technology.51 When ordering tests and examinations we cannot evade our responsibility by referring to vague conceptions of Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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ANALYSIS
technological imperatives, “progress,” or uninformed patients’ demands. We must ensure that we are not overly enthusiastic about new technology and adopt perspectives that grasp our ambivalence towards it, both controlling and feeling controlled. We can do so by understanding how technology expands human agency and perspective but at the same time frames and directs us.62 We also need to acknowledge how technology has become more than a neutral means for a human end,45 63 and how we address it as both an artefact and an actor.64 Although it is important to stimulate innovation we should restrain implementation. Only technology that has shown real benefit should be put into routine practice because access to technology is the most important determinant use in healthcare. 65 Technology assessment and transparent appraisal has to be strengthened to assure benefits for patients.42 Devices must be as critically assessed as drugs.66 67 Patients also need to be better informed about the uncertainties in benefits and risks of technologies, not only about the hyped gains. Their say should be acknowledged in the development, assessment, implementation, and use of technology. In order to use technology to help and not harm, we need to reflect and to take responsibility. To cultivate and boost its true benefits, we must avoid the allures and acknowledge the limits of technology.We must strive to bring our abilities to contemplate on the use of technologies to match our abilities to produce and use them. This will ensure we avoid becoming tragic heroes, succumbing as a result of our best endeavours. We believe that the new is better than the old, that the advanced is better than the simple, that more is better than little
I thank H Gilbert Welch and two reviewers and the editor for their valuable comments and suggestions. Part of this research has been supported by the Commonwealth Fund through the Harkness Fellowship. The views presented here are not necessarily those of the Commonwealth Fund. Competing interests: I have read and understood BMJ policy on declaration of interests and have no interests to declare. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ 2013;347:f4706. Moynihan R. Science of overdiagnosis to be served up with a good dose of humility. BMJ 2013;347:f5157. Moynihan R, Glassock R, Doust J. Chronic kidney disease controversy: how expanding definitions are unnecessarily labelling many people as diseased. BMJ 2013;347:f4298. Welch HG, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health . Beacon Press, 2011. Wiener RS, Schwartz LM, Woloshin S. When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found. BMJ 2013;347:f3368. Le Couteur DG, Doust J, Creasey H, Brayne C. Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis. BMJ 2013;347:f5125. Moynihan R, Smith R. Too much medicine? BMJ 2002;324:859-60. Richards P. Too much medicine? BMJ 1999;318:268. Brownlee S. Overtreated: why too much medicine is making us sicker and poorer : Bloomsbury, 2007. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012;344:e3502. Payer L. Disease-mongers: how doctors, drug companies, and insurers are making you feel sick : Wiley, 2006. Illich I. Limits to medicine . Penguin, 1976. Bodenheimer T. High and rising health care costs. Part 2: technologic innovation. Ann Intern Med 2005;142:932-7. Prevention CfDCa. Health, United States, 2009 with special feature on medical technology. US Department of Health and Human Services, 2009. Dybczak K, Przywara B. The role of technology on health care expenditure in the EU. European Economy-Economic Paper 400. Directorate General for Economic and Monetary Affairs, 2010. Sorenson C, Drummond M, Bhuiyan Khan B. Medical technology as a key driver of rising health expenditure: disentangling the relationship. ClinicoEconomics and Outcomes Research 2013;5:223-34. Carrier ER, Dowling M, Berenson RA. Hospitals’ geographic expansion in quest of well-insured patients: will the outcome be better care, more cost, or both? Health Affairs (Project Hope) 2012;31:827-35.
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18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63
Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA 1999;281:446-53. Fryback DG, Thornbury JR. The efficacy of diagnostic imaging. Med Decision Making 1991;11:88-94. Burge AJ, Freeman KD, Klapper PJ, Haramati LB. Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. Clin Radiol 2008;63:381-6. Moynihan RN, Cooke GP, Doust JA, Bero L, Hill S, Glasziou PP. Expanding disease definitions in guidelines and expert panel ties to industry: a cross-sectional study of common conditions in the United States. PLoS Med 2013;10:e1001500. Black WC, Welch HG. Advances in diagnostic imaging and overestimations of disease prevalence and the benefits of therapy. N Engl J Med 1993;328:1237-43. Cundy T, Ackermann E, Ryan EA. Gestational diabetes: new criteria may triple the prevalence but effect on outcomes is unclear. BMJ 2014;348:g1567. Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. BMJ 2014;349:g4485. Hoff G, Bretthauer M, Garborg K, Eide TJ. New polyps, old tricks: controversy about removing benign bowel lesions. BMJ 2013;347:f5843. Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. Am J Roent 2009;193:1167-74. Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med 2014;174:448-54. Herndon MB, Schwartz LM, Woloshin S, Welch HG. Implications of expanding disease definitions: the case of osteoporosis. Health Aff 2007;26:1702-11. De Carvalho TM, Heijnsdijk EA, de Koning HJ. Screening for prostate cancer in the US? Reduce the harms and keep the benefit. Int J Cancer 2015;136:1600-7. Loeb S, Bjurlin MA, Nicholson J, Tammela TL, Penson DF, Carter HB, et al. Overdiagnosis and overtreatment of prostate cancer. Eur Urol 2014;65:1046-55. Sandhu GS, Andriole GL. Overdiagnosis of prostate cancer. J Natl Cancer Inst Mono 2012;45:146-51. Hodgkinson J, Mant J, Martin U, Guo B, Hobbs FD, Deeks JJ, et al. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ 2011;342:d3621. Luks VP, Vandemheen KL, Aaron SD. Confirmation of asthma in an era of overdiagnosis. Eur Resp J 2010;36:255-60. Appleby J, Raleigh V, Frosini F, Bevan G, Gao H, Lyscom T. Variation in healthcare. King’s Fund, 2011. Wennberg E. Tracking medicine . Oxford University Press, 2010. Lin GA, Dudley RA, Redberg RF. Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study. J Gen Intern Med 2008;23:1458-63. Augsburger JJ. Unnecessary clinical tests in ophthalmology. Trans Am Ophthalmol Soc 2005;103:143-6; discussion 46-7. Gabbay J, Walley T. Introducing new health interventions. BMJ 2006;332:64-5. Pedersen T, Nicholson A, Hovhannisyan K, Moller AM, Smith AE, Lewis SR. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev 2014;3:CD002013. Ho C, Tsakonas E, Tran K, Cimon K, Severn M, Mierzwinski-Urban M et al. Robot-assisted surgery compared with open surgery and laparoscopic surgery. Clinical effectiveness and economic analyses. Canadian Agency for Drugs and Technologies in Health, 2011. Haas M, Hall J, Viney R, Gallego G. Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Austr Health Rev 2012;36:148-52. Henshall C, Schuller T, Mardhani-Bayne L. Using health technology assessment to support optimal use of technologies in current practice: the challenge of “disinvestment.” Int J Technol Assess Health Care 2012;28:203-10. Fuchs VR, Sox HC Jr. Physicians’ views of the relative importance of thirty medical innovations. Health Aff (Project Hope) 2001;20:30-42. Luft HS, Robinson JC, Garnick DW, Maerki SC, McPhee SJ. The role of specialized clinical services in competition among hospitals. Inquiry 1986;23:83-94. Hofmann B. When means become ends: technology producing values. Seminar.net 2006;2. http://seminar.net/index.php/volume-2-issue-2-2006-previousissuesmeny-114/ 66-when-means-become-ends-technology-producing-values. Album D, Westin S. Do diseases have a prestige hierarchy? A survey among physicians and medical students. Soc Sci Med 2008;66:182-8. Wolf S, Berle B. The technological imperative in medicine . Plenum Press, 1981. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002;324:886-91. Cassell E. The sorcerer’s broom. Medicine’s rampant technology. Hastings Center Report 1993;23:32-9. Winner L. Autonomous technology . MIT Press, 1977. Hofmann B. Is there a technological imperative in health care? Int J Technol Assess Health Care 2002;18:675-89. Davis A. Medicine and its technology. An introduction to the history of medical instrumentation . Greenwood, 1981. Boenink M. Molecular medicine and concepts of disease: the ethical value of a conceptual analysis of emerging biomedical technologies. Med Health Care Philos 2010;13:11-23. Hofmann B. The technological invention of disease—on disease, technology and values. University of Oslo, 2002. Prasad V, Rho J, Cifu A. The diagnosis and treatment of pulmonary embolism: a metaphor for medicine in the evidence-based medicine era. Arch Intern Med 2012;172:955-8. Brito JP, Gionfriddo M, Morris JC, Montori VM. Overdiagnosis of thyroid cancer and Graves’ disease. Thyroid 2014;24:402-3. Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010;102:605-13. Welch HG, Woloshin S, Schwartz L. Overdiagnosed: making people sick in pursuit of health. Beacon Press, 2011. Colla CH, Morden NE, Sequist TD, Schpero WL, Rosenthal MB. Choosing wisely: prevalence and correlates of low-value health care services in the United States. J Gen Intern Med 2015;30:221-8. Collado M. How prevalent and costly are Choosing Wisely low-value services? Evidence from Medicare beneficiaries. Find Brief 2014;42(4):1-2. National Institute for Health and Care Excellence. NICE “do not do” recommendations. NICE, 2011. Heidegger M. The question concerning technology and other essays . Harper and Row, 1977. Hofmann B. On the value-ladenness of technology in medicine. Med Health Care Philos 2001;4:335-46.
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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64 65 66 67
Latour B. Reassembling the social: an introduction to actor-network-theory . Oxford University Press, 2005. Chernew ME, Jacobson PD, Hofer TP, Aaronson KD, Fendrick AM. Barriers to constraining health care cost growth. Health Aff (Project Hope) 2004;23:122-8. Wilmshurst P. The regulation of medical devices. Unsatisfactory, unscientific, and in need of a major overhaul. BMJ 2011;342:d2822. Dhruva SS, Bero LA, Redberg RF. Strength of study evidence examined by the FDA in premarket approval of cardiovascular devices. JAMA 2009;302:2679-85.
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Accepted: 10 December 2014 Cite this as: BMJ 2015;350:h705 © BMJ Publishing Group Ltd 2015
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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ANALYSIS
Tables Table Table| 1 Examples of conditions where technology has change detection of disease
10
Condition
Technology
Change
Pulmonary embolism
Pulmonary angiography (1930), ventilation perfusion scintigraphy (1964), computed tomography pulmonary angiography (1998)
Thyroid cancer
Neck ultrasonography (1980), guided biopsy (1990), CT, Increased detection (and removal) of small papillary cancers/nodules. MRI (1996), ultrasound guided aspiration of thyroid nodules More patients receive a diagnosis after incidental findings than after (2002) evaluation of a symptomatic or palpable nodule1
Gestational diabetes
From dual step test to single glucose value with reduced thresholds
Prediabetes
Impaired glucose tolerance by glucose challenge test (1979), Technological changes combined with lowering threshold results in a impaired glucose tolerance by a fasting plasma glucose test twofold to threefold increase in prevalence24 (1997), glycated haemoglobin (2009)
Colon cancer
Sigmoidoscopy, colonoscopy, high definition endoscopy with Serrated polyps are identified and removed, although risky and without modern enhancement techniques knowledge about outcome.25
Dissection of carotid or vertebral arteries
Doppler sonography, magnetic resonance angiography, CT 3-10 times increase in detection rate26 angiography
Breast cancer
Clinical examination to (digital) mammography screening
Chronic kidney disease
Serum creatinine or cystatin C levels (to estimate glomerular Almost 14% in the US are labelled as having chronic kidney disease3 filtration rate) and an assessment of kidney damage (eg, from testing albuminuria)
Osteoporosis
Dual energy x ray absorptiometry
Changing the treatment threshold (T score ≤2.0) makes more than half of women age ≥65 treated as diseased28
Prostate cancer
Prostate specific antigen
Proportion of overdiagnosis in screen detected cases varies between 22% and 67%29-31
Hypertension
Blood pressure monitoring
Substantial overdiagnosis when treatment decisions are based on clinic or home blood pressure alone.34 Without BP measurement, hypertension would not be considered to be a disease
Asthma
Stethoscope, spirometer
30% of people who had asthma diagnosed were overdiagnosed33
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80% increase in pulmonary embolism from 1998 to 2006 with little reduction in mortality5
New diagnostic criteria triple the prevalence of gestational diabetes with unclear effect on outcomes23
For every 1000 US women aged 50, 490-670 will have at least 1 false alarm, and 3-14 will be overdiagnosed and treated needlessly while 0.3 to 3.2 will avoid a breast cancer death when screened annually from age 4027
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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ANALYSIS
Table Table| 2 Examples of drivers of technology implementation in healthcare Driver Industry
Functions and mechanisms Develops and tests technology Promotes technology in alliance with professionals or patients
Professionals
Improving care, promoting professional interests and prestige Fear of missing “silent killers,” treatment opportunities, and decision regret Fear of uncertainty and litigation (defensive medicine) Anxiolytic use of technology: “non-essential technical examinations” to satisfy or calm patients Biased beliefs (myths): high tech is better than low tech or no tech; what is counted counts over what is told; new is better than old
Hospital managers Technology is used strategically to recruit health staff as well as patients Patients
Demand advanced technologies, believing advanced and more is better
Policy makers
Health technology is used to obtain other welfare goals than health
Regulators
Increased demand for documentation Technology promises short sighted solutions
Society
A general belief in technological progress and an aversion to risk and uncertainty Biased beliefs (myths): new is better than the old, advanced is better than the simple, more is better than little, to know is better than not to know, to know early is better than to know later, images are better than numbers
Media
Enhancing hype and selling fear and hope
Science
Publication bias and repeated statistical analysis also promotes the (false) conception of technological progress
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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ANALYSIS
Figures
Fig 1 Self perpetuating loop of development in diagnostic technology
Fig 2 Some spin-off challenges from the self perpetuating loop of diagnostic technology
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Page 1 of 7
Analysis
ANALYSIS Too much technology Our abilities to produce and use technologies appear to outrun our abilities to reflect on their application. To avoid becoming technological titans and ethical Lilliputians, Bjørn Morten Hofmann argues we need a more reflective and responsible implementation of health technology Bjørn Morten Hofmann researcher
123
University College of Gjøvik, PO Box 1, N-2802 Gjøvik, Norway; 2Centre for Medical Ethics, University of Oslo, Oslo, Norway; 3Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA 1
Medical excess has been recognised as a key problem in modern healthcare.1-9 Overdiagnosis and overtreatment have been identified in a wide range of diseases,4 10 and medicalisation of ordinary human conditions has been heavily criticised.11 12 We seem to do too much of a good thing. Technology tends to have a crucial role in our propensity to excess.
From the invention of the stethoscope in Paris in 1816 to the whole genome sequencing of fetal cell-free DNA in a pregnant woman’s blood, technology has been a transforming factor in medicine. Technology has played a key part in moving medicine from the 2400 disease entities described in Sauvages’ 1793 Nosologica methodica to ICD-10 with more than 40 000 entries. Medical technology has also been a driving force in the growth of expenditure on health.13-15 It by far outweighs other price driving factors, such as an ageing population, increased public demand, income growth, raising prices, and reduced organisational efficiency. Half of the increase in the overall costs in healthcare are attributed to technology.16 Having a new technology raises the clout of hospitals and specialists and spurs a technological arms race.17 Technology is used beyond its benefit and sometimes even when it is harmful.18 No doubt, medical technology is a cornerstone in reducing ailment and improving health. Nevertheless, we need to address the challenges when the tool for improving health makes us diseased and when our means become our ends. Below I identify and analyse the mechanisms and the drivers behind using technology beyond its benefit and suggest measures to handle technology in a reflective and responsible manner.
Self perpetuating loop of diagnostics
The pervasive use of technology in healthcare is driven by a positive feedback loop in clinical diagnostics (fig 1⇓). The expansion of diagnostic technology often starts with a technical improvement—for example, increased spatial resolution of a diagnostic ultrasound machine. Such advances in technical performance may not result in better diagnostics—we may only see better what we already know.19 But sometimes they result in increased accuracy, in terms of improved sensitivity and
specificity.19 A shift from ventilation perfusion scintigraphy to computed tomography pulmonary angiography increases the accuracy in diagnosing pulmonary emboli, revealing more cases of pulmonary embolism.20 This is perceived as a success, which results in closer scrutiny of the images and more frequent testing, leading to detection of milder cases21 and a higher diagnostic yield.22 Computed tomography pulmonary angiography increased the detection of pulmonary embolism by 80% from 1998 to 2006.5 Hence, the technological improvement uncovers a hitherto “under-detected” health problem.1 5 This increases the notion of success and the interest in diagnostic technologies. Correspondingly, the increased number of diseased people spurs therapeutic attention. We start treating people who were previously not treated.18 Hence, ever milder cases are treated, as well as cases that would otherwise not have been detected. Computed tomography, magnetic resonance imaging (MRI), and ultrasound guided aspiration of thyroid nodules, for example, have increased the detection (and removal) of small papillary cancers.1 Treating milder cases improves outcomes, enhancing the impression of success, which in turn boosts technological innovation.18 Table 1⇓ gives some other examples where technology has changed the prevalence of disease.
The profession and society seek technology The pervasive use of technology in healthcare has many drivers (table 2⇓). At the systems level, the supply of technology drives demand.34 35 If an MRI scanner is available it is used. The same goes for blood tests and surgery.35 Technologies are widely used without evidence of their effectiveness, safety, and efficiency18 35-38 and sometimes even though there is evidence that they are not efficient—for example, pulse oximetry for perioperative monitoring and robot surgery.39 40 Occasionally technologies are used even when we know they are harmful.18 We are more eager to invest in new technology with little evidence than to disinvest in technology with evidence for little or no effectiveness.41 42
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
Page 2 of 7
ANALYSIS
Moreover, high tech is associated with high importance43 and high quality.44 Technology is used strategically to attract specialists and patients44 and impels a technological arms race.17 If your competitor has handheld ultrasound machines or a 3T MRI machine, you need to have them as well. Technology transforms from being instrumental to improving health to become a means of power and prestige, or even an end in itself.45 Professionals associate advanced technology with higher prestige both of diseases and specialties.46 Such perspectives are shared by patients, public, and the media, who request high tech interventions. Accordingly, general social myths drive the belief in technology. We believe that the new is better than the old, that the advanced is better than the simple, that more is better than little, that to know is better than not to know, and that to detect early is better than later. If doctors do not order a test, CT, or MRI people think they do not care. This is reinforced by the media. Angry or sad people who did not get the technology they should have hit the headlines, but those who have been overdiagnosed or overtreated are happy to have been “saved.” Additionally, it has been argued that one of the major drivers is technology itself: there is a technological imperative,47 pushing technological innovation beyond healthcare needs, where technology defines diseases and provides the cures.11 48 This technology push has been explained by technology’s compensation for human deficiencies49 and as technology being autonomous.50 Technology has become an independent and powerful actor driving healthcare beyond its original goals. However, such (deterministic) views make us serfs of technology and reduce our responsibility. Paradoxically, we become servants of the technology we design, produce, implement, and use.51 The self perpetuating loop of diagnostic technologies and the identified drivers are helpful in understanding and addressing the pervasive role of technology in healthcare. However, they miss a basic bond between medicine and technology: how technology constitutes our conception of disease.
Technological construction of disease Technology is changing the meaning of disease.52 53 More specifically, technology changes our conception of disease at three levels.54 Firstly, it provides the entities that define disease. Technology such as biochemical analysers, cytometers, and DNA sequencers provides access to enzymes, T cells, or specific strands of DNA. Hence, the core elements of diseases we find in definitions in medical textbooks are constituted by technology. Secondly, it is directing and structuring our knowledge of disease. One day our knowledge of myocardial infarction is based on the electrical activity in the heart measured by electrocardiography, the next it is more based on measurement of troponin in the blood. Thirdly, disease is constituted by technology through practice. If we can measure or manipulate something, it tends to become a disease—for example, hypertension and cholesterolaemia would not be relevant to medicine if we could not measure or manipulate blood pressure or cholesterol. Hence, the expansion of technology profoundly extends our conception of disease—for good and for bad.
Implications of pervasive technology Fig 2⇓ shows some of the implications of the self perpetuating loop of diagnostic technology that are supported by the many
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drivers of technology and the technological constitution of disease. These include: Enhanced leaps of belief—The apparent success of diagnosing and treating more results in unwarranted enthusiasm among professionals and industry, hyped beliefs and demands among patients and the media, as well as unrealistic expectations among policy makers. Benefits seem self evident while downsides are veiled or ignored Good tests become poor—A more accurate diagnostic test may result in poorer outcome if the test is used for ever healthier people. If a diagnostic test increases its sensitivity and specificity from 0.80 to 0.95, the chance that a given positive test result is correct decreases from 0.8 to 0.16 if the prevalence decreases from 1 in 2 to 1 in 100. Hence, technical improvements do not guarantee clinical improvements Detecting more does not help people—Detection of cases does not mean that more patients are treated or that more lives are saved.1 55 56 Instead, more people become diseased, as disease categories are widened or everyday conditions become recategorised as disease. Technical improvements make us detect cases that would otherwise not have caused symptoms or death—that is, overdiagnosis— which subsequently leads to overtreatment.10 57 58 Hence, our technological endeavours to help become futile or even harmful Increased activity—Intensified diagnostic activity generates incidental findings. While some “incidentalomas” save lives, many do not—for example, incidental detection of thyroid cancer with CT or MRI does not reduce symptoms or death.1 Follow-up of diagnostic findings produces other incidental findings. Hence, we do more but less with measurable outcomes for people’s health Increased health anxiety—The raised disease prevalence and increased awareness of health problems make people more concerned and anxious about their health, spurring even more testing and treatment Increased cost—The increase in screening programmes, diagnostic tests, incidental findings, and follow-up substantially raises health expenditure.13-15 This drains resources from areas where technology is really effective and innovations are really needed Reduced value—When the predictive value of diagnostic tests is low, more people are overdiagnosed and overtreated, and people with social or other problems are given medical labels, the usefulness of healthcare endeavours is deflated Undermining trust—With increased awareness of excessive healthcare,7 9 53 low value healthcare,59 60 and “not to do” health services,61 people may lose trust—the cornerstone of healthcare provision.
What we can do? Uncritical implementation and use of technology excites excessive medicine. One reason for this is that technology is deeply ingrained in our conception of disease and our culture. It spurs a series of leaps of faith. Therefore, the first thing we have to do is to get rid of truisms, such as that more is better than less, new is better than old, and advanced is more accurate than simple. We must also acknowledge our responsibility for the development, implementation, and use of medical technology.51 When ordering tests and examinations we cannot evade our responsibility by referring to vague conceptions of Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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ANALYSIS
technological imperatives, “progress,” or uninformed patients’ demands. We must ensure that we are not overly enthusiastic about new technology and adopt perspectives that grasp our ambivalence towards it, both controlling and feeling controlled. We can do so by understanding how technology expands human agency and perspective but at the same time frames and directs us.62 We also need to acknowledge how technology has become more than a neutral means for a human end,45 63 and how we address it as both an artefact and an actor.64 Although it is important to stimulate innovation we should restrain implementation. Only technology that has shown real benefit should be put into routine practice because access to technology is the most important determinant use in healthcare. 65 Technology assessment and transparent appraisal has to be strengthened to assure benefits for patients.42 Devices must be as critically assessed as drugs.66 67 Patients also need to be better informed about the uncertainties in benefits and risks of technologies, not only about the hyped gains. Their say should be acknowledged in the development, assessment, implementation, and use of technology. In order to use technology to help and not harm, we need to reflect and to take responsibility. To cultivate and boost its true benefits, we must avoid the allures and acknowledge the limits of technology.We must strive to bring our abilities to contemplate on the use of technologies to match our abilities to produce and use them. This will ensure we avoid becoming tragic heroes, succumbing as a result of our best endeavours. We believe that the new is better than the old, that the advanced is better than the simple, that more is better than little
I thank H Gilbert Welch and two reviewers and the editor for their valuable comments and suggestions. Part of this research has been supported by the Commonwealth Fund through the Harkness Fellowship. The views presented here are not necessarily those of the Commonwealth Fund. Competing interests: I have read and understood BMJ policy on declaration of interests and have no interests to declare. Provenance and peer review: Not commissioned; externally peer reviewed. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
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Gabbay J, Walley T. Introducing new health interventions. BMJ 2006;332:64-5. Pedersen T, Nicholson A, Hovhannisyan K, Moller AM, Smith AE, Lewis SR. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev 2014;3:CD002013. Ho C, Tsakonas E, Tran K, Cimon K, Severn M, Mierzwinski-Urban M et al. Robot-assisted surgery compared with open surgery and laparoscopic surgery. Clinical effectiveness and economic analyses. Canadian Agency for Drugs and Technologies in Health, 2011. Haas M, Hall J, Viney R, Gallego G. Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Austr Health Rev 2012;36:148-52. Henshall C, Schuller T, Mardhani-Bayne L. Using health technology assessment to support optimal use of technologies in current practice: the challenge of “disinvestment.” Int J Technol Assess Health Care 2012;28:203-10. Fuchs VR, Sox HC Jr. Physicians’ views of the relative importance of thirty medical innovations. 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Accepted: 10 December 2014 Cite this as: BMJ 2015;350:h705 © BMJ Publishing Group Ltd 2015
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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Tables Table Table| 1 Examples of conditions where technology has change detection of disease
10
Condition
Technology
Change
Pulmonary embolism
Pulmonary angiography (1930), ventilation perfusion scintigraphy (1964), computed tomography pulmonary angiography (1998)
Thyroid cancer
Neck ultrasonography (1980), guided biopsy (1990), CT, Increased detection (and removal) of small papillary cancers/nodules. MRI (1996), ultrasound guided aspiration of thyroid nodules More patients receive a diagnosis after incidental findings than after (2002) evaluation of a symptomatic or palpable nodule1
Gestational diabetes
From dual step test to single glucose value with reduced thresholds
Prediabetes
Impaired glucose tolerance by glucose challenge test (1979), Technological changes combined with lowering threshold results in a impaired glucose tolerance by a fasting plasma glucose test twofold to threefold increase in prevalence24 (1997), glycated haemoglobin (2009)
Colon cancer
Sigmoidoscopy, colonoscopy, high definition endoscopy with Serrated polyps are identified and removed, although risky and without modern enhancement techniques knowledge about outcome.25
Dissection of carotid or vertebral arteries
Doppler sonography, magnetic resonance angiography, CT 3-10 times increase in detection rate26 angiography
Breast cancer
Clinical examination to (digital) mammography screening
Chronic kidney disease
Serum creatinine or cystatin C levels (to estimate glomerular Almost 14% in the US are labelled as having chronic kidney disease3 filtration rate) and an assessment of kidney damage (eg, from testing albuminuria)
Osteoporosis
Dual energy x ray absorptiometry
Changing the treatment threshold (T score ≤2.0) makes more than half of women age ≥65 treated as diseased28
Prostate cancer
Prostate specific antigen
Proportion of overdiagnosis in screen detected cases varies between 22% and 67%29-31
Hypertension
Blood pressure monitoring
Substantial overdiagnosis when treatment decisions are based on clinic or home blood pressure alone.34 Without BP measurement, hypertension would not be considered to be a disease
Asthma
Stethoscope, spirometer
30% of people who had asthma diagnosed were overdiagnosed33
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80% increase in pulmonary embolism from 1998 to 2006 with little reduction in mortality5
New diagnostic criteria triple the prevalence of gestational diabetes with unclear effect on outcomes23
For every 1000 US women aged 50, 490-670 will have at least 1 false alarm, and 3-14 will be overdiagnosed and treated needlessly while 0.3 to 3.2 will avoid a breast cancer death when screened annually from age 4027
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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Table Table| 2 Examples of drivers of technology implementation in healthcare Driver Industry
Functions and mechanisms Develops and tests technology Promotes technology in alliance with professionals or patients
Professionals
Improving care, promoting professional interests and prestige Fear of missing “silent killers,” treatment opportunities, and decision regret Fear of uncertainty and litigation (defensive medicine) Anxiolytic use of technology: “non-essential technical examinations” to satisfy or calm patients Biased beliefs (myths): high tech is better than low tech or no tech; what is counted counts over what is told; new is better than old
Hospital managers Technology is used strategically to recruit health staff as well as patients Patients
Demand advanced technologies, believing advanced and more is better
Policy makers
Health technology is used to obtain other welfare goals than health
Regulators
Increased demand for documentation Technology promises short sighted solutions
Society
A general belief in technological progress and an aversion to risk and uncertainty Biased beliefs (myths): new is better than the old, advanced is better than the simple, more is better than little, to know is better than not to know, to know early is better than to know later, images are better than numbers
Media
Enhancing hype and selling fear and hope
Science
Publication bias and repeated statistical analysis also promotes the (false) conception of technological progress
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BMJ 2015;350:h705 doi: 10.1136/bmj.h705 (Published 13 February 2015)
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Figures
Fig 1 Self perpetuating loop of development in diagnostic technology
Fig 2 Some spin-off challenges from the self perpetuating loop of diagnostic technology
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