Overdiagnosis and overtreatment: generalists--it's time for a grassroots revolution.

have always been with us, but the scale and institutionalisation of overdiagnosis and overtreatment have expanded exponentially in the last few decades. Modern concern has been articulated through worldwide movements such as the Preventing Overdiagnosis conferences, campaigns such as the BMJ’s ‘Too Much Medicine’, JAMA’s ‘Less is More’, Italy’s ‘Slow Medicine’ movement, and the US (now international) ‘Choosing Wisely’ project. In 2014 the Royal College of General Practitioners (RCGP) established its Standing Group on Overdiagnosis (Supporting Shared Decisions in Health Care). Overdiagnosis has been defined simply as ‘... when people without symptoms are diagnosed with a disease that ultimately will not cause them symptoms or early death’ and is also used as an umbrella term to include ‘... the related problems of overmedicalisation and subsequent overtreatment, diagnosis creep, shifting thresholds and disease mongering’.1 Some commentators use Too Much Medicine to embrace such wider issues.2 Drivers of overdiagnosis are well described. Advancing technology allows detection of disease at earlier stages or ‘pre-disease’ states. Well-intentioned enthusiasm and vested interests combine to lower treatment and intervention thresholds so that ever larger sections of the asymptomatic population acquire diagnoses, risk factors, or disease labels. This process is supported by medicolegal fear, and by payment and performance indicators that reward over-activity. It has led to a guideline culture that has unintentionally evolved to squeeze out nuanced, person-centred decision making. Underlying all this are little challenged, deeply intuitive narratives around the supposed benefits of early detection and intervention that are difficult to unpick for professionals and public alike.1,3 This leads to real harms. The psychological burden of acquiring a disease label may appear hard to quantify — partly because of under-research — for something like chronic kidney disease (CKD). However, it becomes more obvious when considering a false-positive diagnosis of dementia or a screening overdiagnosis of breast cancer. Patients are exposed to treatment harms, from the mild to the fatal, and waste of resources is inevitable on a grand scale. The critical issue of opportunity cost may be raised but disregarded in costeffectiveness decisions.4 None of this is simple; overdiagnosis and overtreatment arise as consequences of activities that have a degree of benefit to some. Difficult questions arise about how harms and benefits are weighed or perceived, and how to offer real choice to patients rather than simply what the contract or guidelines direct. We believe that generalists have specific expertise here. Drivers for clinical practice tend to originate from specialist research. Specialists dealing with single conditions may have disease-specific endpoints in mind, but these need to be prioritised by the patient in the context of their wider health issues and perception of risk and benefit. For the clinician, these endpoints need to be prioritised with the knowledge of consequences of interventions on the wider population or system. Generalists are handed the responsibility of enacting population-level interventions to achieve specialist goals but we treat individuals who may, rightly and entirely reasonably, take a different view.