If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Corresponding author at: Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, PO Box 1068, Blindern, 0316 Oslo, Norway.
Department of Pharmacy, Section for Pharmacology and Pharmaceutical Biosciences, University of Oslo, Oslo, NorwayOslo Hospital Pharmacy, Hospital Pharmacies Enterprise, South Eastern Norway, Norway
Department for the Health Sciences, Norwegian University of Science and Technology (NTNU), Gjøvik, NorwayCentre of Medical Ethics, University of Oslo, PO Box 1130, Blindern, N-0318 Oslo, Norway
Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions.
•
Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to reducing the persons’ suffering and should be introduced to make people less ill.
•
Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation and deprescribing.
•
As diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient and through shared decision making.
Abstract
Diagnosing constitutes a substantial part of healthcare work and triggers a wide range of actions including the prescription of medicines. Dediagnosing is proposed as a novel framework for removing diagnoses that do not contribute to the reduction of persons’ suffering and should be introduced to make people less ill. Dediagnosing comes together with other efforts to reduce overuse, such as deimplementation, deprescribing, decommissioning, and disinvestment. Because diagnoses may influence identity construction and social rights, dediagnosing must be conducted in close collaboration with the patient.
The vast progress in science and technology has greatly increased the number of diseases. Today, the International Classification of Diseases (ICD-11) consists of approximately 55,000 unique codes for diseases. Together with extensive progress in treatments and increased life expectancy, more people have diseases and receive treatment for a longer time. More sensitive and predictive tests detect diseases earlier, sometimes too early, resulting in overdiagnosis and overtreatment.[
] Additionally, more behaviours, experiences, and social issues are given diagnoses. All these factors increase the number of people being diagnosed and drive multimorbidity and polypharmacy.[
] This poses major challenges to healthcare systems on both the extension of care and the expertise required, and raises the question of whether we have gone too far in diagnosing.
Recently, some counter-initiatives have been proposed.[
] To further address the problem of excessive diagnoses, we provide specific action-guiding content to the concept of dediagnosing to be used as a framework to avoid nonbeneficial diagnosing and provide appropriate care across patient populations and health care levels. We also address the implications and how dediagnosing can be used to reduce multimorbidity, polypharmacy, and to make people less ill.
1. Diagnosing is a substantial part of healthcare
For positive reasons, much attention goes into diagnosing. Accurate diagnosing is one of the main principles of modern medicine, sometimes even afforded with higher status than successful treatment.[
] Moreover, patients expect and request diagnoses. As pointed out by Nuland, diagnosis is “the most critical of a physician's skills… It is every doctor's measure of his abilities; it is the most important ingredient in his professional self image.”[
Nuland S. (2014) How we die: reflections on life's final chapter. New York, NY: Knopf; 1994, here quoted from Graber M.L., Plebani M. Diagnosis: a new era, a new journal. Diagnosis (Berl) 1: 1-2.
] Physicians spend much of their time in diagnosing patients. However, neither much time nor focus appears to be spent on reassessing and removing obsolete diagnoses. Diagnoses are found but rarely lost.[
One reason why diagnosing plays such a crucial role is because the healthcare system persistently relies on formal diagnoses for healthcare attention, treatment pathways, and economic reimbursement. While diagnoses and treatments are often beneficial, recent research has increased awareness of the problem with “too much medicine”.[
As diagnoses are powerful, their use warrants careful consideration. A diagnosis is defined as an identification of a bodily or mental condition, e.g., by symptoms, paraclinical signs, or markers, which are considered to be of disadvantage or harm to a person's health.[
Diagnoses warrant attention from health professionals, but are also attributed to different status and prestige. Acute and actionable diseases in specific organs located in the upper part of the body have higher status than chronic diffuse diseases related to lower parts of the body.[
] Diagnoses influence peoples’ identity construction and change the perception of a person for the person herself, their caregivers, and society. To reduce peoples’ suffering, diagnoses direct a variety of actions including treatments and doctor's appointments. Such actions affect peoples’ everyday life.[
Do combined pharmacist and prescriber efforts on medication reconciliation reduce postdischarge patient emergency department visits and hospital readmissions?.
Strauss A Unending work and care. 1998, here quoted from Duguay C., Gallagher F., Fortin M. The experience of adults with multimorbidity: a qualitative study.
] Multimorbid patients report powerlessness, worthlessness, uncertainty, and anticipation related to their health status: “Sitting on a shaky chair, not knowing whether it would collapse or stay in place” was used as a metaphor to describe his situation, by one of them.[
Free from social obligations such as work (attributed by sick leave).
Induce grounded or ungrounded anxiety: The latter because of false labels / false-positive test results.
Apply unnecessary labels and treatment: Because of overdiagnosis; what is found will not develop into suffering.
Imply status and prestige: Diagnosed have different status and prestige.
Induce stigma and discrimination: Specific diagnoses can result in stigma and discrimination.
Give a psychological and existential burden: Through stigmatization and discrimination, but also as an existential threat.
In summary, diagnoses can be polyvalent; they can relieve and cause worries – at the same time – they can result in cure, but also unnecessary treatment and harm.[
] While some persons fight to obtain diagnoses, others struggle to get rid of them (e.g., psychiatric diagnoses). Accordingly, we need to differentiate and remove diagnoses that do not reduce persons’ suffering, i.e., we should dediagnose to make people less ill.
3. Dediagnosing to stop the unwarranted disease expansion
The vast expansion of diagnoses can be explained by the multiple disease expansion illustrated in Fig. 1.[27,28] In particular, two drivers for disease expansion have gained much attention: medicalization; i.e., non medical aspects of human life made medical problems, and overdiagnosis; i.e., diagnosing a biomedical condition that in the absence of testing would not cause symptoms, disease, or death in the person's lifetime.[
] However, how the healthcare system is organized has not gained enough attention as a driver for diagnosing. We will argue that this may be an additional important reason for expansion included in the pragmatic expansion.
Fig. 1Seven dimensions of disease expansion. Adopted from
] Seeing a specialist increases the chance of specific diagnoses. For example, seeing a pediatric allergist significantly increase the chance of being diagnosed with allergic rhinitis compared to that when seeing a pediatrician.[
Altogether, despite the very best intentions, the way we organize the healthcare system fuels disease expansion and inflates the number of diagnoses. In our eagerness to help, we make people ill.[
] However, a healthcare system making people more ill is not sustainable as it will undermine trust and demand in the long run. While a change in culture may take several years, dediagnosing is a first step toward making this a target for improvement.
4. Why dediagnosing?
As indicated, more healthcare does not always result in better outcomes or satisfaction with care.[
Consequences of extending diagnoses beyond what benefits people's health.
For the person
Unnecessary labels, concerns, and testing
Unnecessary treatment burden, including side-effects
Inappropriate polypharmacy, risk of drug-drug and drug-disease interactions
Increased use of healthcare resources and own time and resources
For caregivers
Unnecessary concerns
Extra caregiver burdens
For society
Increased demands on the healthcare sector
Increased need for healthcare professionals in general
Increased need for healthcare professionals with expertise on multimorbidity and polypharmacy
Increased financial burden
Reduced professional integrity and trust in the healthcare services
Another reason for diagnosis reassessment is the inevitable diagnostic uncertainty. In a recent multicenter study of patients with physician-diagnosed asthma within the past five years, a re-evaluation ruled out asthma in one-third of the patients.[
] Of these patients, more than 40% were objectively proven to have had asthma through documented assessments of airflow limitation at the original time of diagnosis.[
] Additionally, diagnostic errors are frequent and it has been estimated that most people likely will experience a minimum of one such error in their lifetime.[
Diagnoses in medical records are seldom questioned which indicates the need to introduce dediagnosing. Reassessment of technologies has gained traction[
] but a full framework of dediagnosing has not been suggested thus far. The first step of dediagnosing constitutes verifying the diagnosis. Health records can provide an answer, but information about the tests that formed the basis for a diagnosis: how, by whom, and under what conditions rarely follows the medical record, especially not in the information flow between healthcare levels and institutions.[
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
] If a patient's diagnosis can be verified from the medical record, re-evaluate whether the diagnosis is still relevant or valid: do present test results and guidelines still classify the person to have the diagnosis? Moreover, does the patient still have the measures, symptoms, and/or clinical changes that qualify for the diagnosis today? Both diagnostic criteria and the patient's condition can change over time. Step 2 of dediagnosing includes assessing patient preferences, assessing the actions that each diagnosis triggers, and when and how a diagnosis will benefit and harm the individual patient. Prognostic information (duration of life) can be included in this assessment. Fig. 2 presents the complete procedure for dediagnosing.
Fig. 2Procedure for dediagnosing that consists of two steps; both should be conducted. Diagnostic odysseys are explained by Black et al
We define dediagnosing as the removal of diagnoses that do not contribute to reducing the person's suffering, i.e., when the person is better off without it. Dediagnosing includes but goes beyond removing conditions resolved because of cure, recovery, rehabilitation, or remission (vis mediatrix naturae - the healing power of nature),[
] Moreover, it also goes beyond “diagnostic revision” and “diagnostic review,” which may focus on correcting diagnoses.
Dediagnosing is a framework for an overall concern for persons’ health. Importantly, while there are many reasons for removing diagnoses, dediagnosing refers to the active removal of one or more diagnoses; because an overall assessment reveals that specific diagnoses are more harmful than beneficial to the person's health. To achieve success, targeting the drivers of excessive diagnosis will be crucial during the dediagnosing process. Fig. 3 provides an overview of typical drivers of diagnosis.
Fig. 3Overview of typical drivers of diagnosis. Adopted from
Boy, 20 years old, diagnosed with ADHD in his childhood.
Woman, 56 years old, diagnosed with diabetes mellitus type 2 four years ago.
Woman 94 years old, diagnosed with osteoporosis decades ago.
Dediagnosing
Step 1
As a 20-year-old, he has no ongoing symptoms that would indicate ADHD. The ADHD diagnosis is not valid anymore.
Since the time of diagnosis, she has started exercising, improved her diet and lost weight. HbA1c has now dropped to <6.5% without antidiabetic drugs. The diabetes mellitus type 2 diagnosis is not valid anymore.
The diagnostic criterion is still present since the woman has experienced several osteoporotic fractures.
Step 2
a) The boy prefers not to have the ADHD diagnosis anymore. b) The ADHD diagnosis trigger special attention regarding the driver's license and stigmatizes. c) The ADHD diagnosis is considered not to be beneficial for the boy, but rather to harm him, see points 2a and 2b.
a) The woman prefers not to have the diabetes mellitus diagnosis anymore. She thinks the diagnosis is stigmatizing. b) The diabetes mellitus diagnosis can trigger prescription of drugs, however, the woman does not need such drugs anymore. The diagnosis also triggers stigmatization. c) The diabetes mellitus diagnosis is considered to harm the patient due to stigmatization.
a) The woman express worries and uncertainty as a result of the osteoporosis diagnosis and the accompanying risk of fractures. b) The osteoporosis diagnosis triggers prescription of non-osteoporotic drugs. However, since life expectancy is considered to be short, non-osteoporotic drugs are deprescribed now. c) The osteoporosis diagnosis is considered to harm the woman due to worries about the risk of fractures.
Health Services and Delivery Research. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study.
Health Serv Deliv Res.2017; 5 (https://doi.org/10.3310/hsdr05220)
A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review.
] However, to move even closer toward the goal of reducing overuse, specialists must also get themselves involved in the process. They will undoubtedly be highly competent to dediagnose within their area of expertise. Therefore, introducing dediagnosing may increase specialists’ participation and contribution to the common overall objective of reducing illness, and not just entrust this task to generalists.
A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review.
Health Services and Delivery Research. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study.
Health Serv Deliv Res.2017; 5 (https://doi.org/10.3310/hsdr05220)
Disinvestment –“the process of (partially or completely) withdrawing health resources from any existing healthcare practices, procedures, technologies, or pharmaceuticals that are deemed to deliver little or no health gain for their cost, and thus, are not efficient health resource allocation” [
ERASE – “Evaluate diagnoses to consider Resolved conditions, Ageing normally and Selecting appropriate targets to Eliminate unnecessary diagnoses and their corresponding medicines”. A primary care led approach for undiagnosing in the elderly [
Little research has been conducted on patients’ eventual psychological sequelae from discontinuation of long-term treatment. This should be considered when dediagnosing or deprescribing is considered. Patients’ potential perceptions have been suggested[
“I was told to take this until I die. Are you saying I'm about to die?”
•
“But won't I get sick without the tablet?”
•
“But my other doctor told me I should never stop this drug. Are you saying (s)he was wrong? Do you know what you're doing?”
Starting with dediagnosing, ahead of deprescribing, may make it easier to understand and accept the process for the patient. If a diagnosis is not present anymore, it must be indisputable and obvious that no further treatment is required. In this manner, dediagnosing combined with deprescribing may lead to less uncertainty for patients.
7. Moving forward
From elaborating the framework and procedure to applying dediagnosing, we must move to active and effective implementation. Moreover, we need to dediagnose in close collaboration with the affected person, taking the person’s perspectives, needs, preferences, and interests into consideration through shared decision making. Dediagnosing may not be expedient for all individuals or in all circumstances. For instance, “cancer survivors” may be cured, but still experience many related ailments.[
] Importantly, the removal of a diagnosis through dediagnosing is independent of future disease recurrence risk. Here, we distinguish between diagnosis, disease, or illness on one side and vulnerability or future risk of disease recurrence on the other. The purpose of dediagnosing is simply to bring diagnoses on par with suffering, and thereby to reduce unnecessary illness. Diagnostics should be less directed by how good we are at identifying and treating specific conditions and more by whether doing so is helpful to people. Hence, shifting from diagnostic reasoning to management reasoning [
The presented novel framework of dediagnosing is based on insights from the philosophy of medicine, ethics, and epidemiology along with extensive clinical experience. It comes together with other efforts to reduce overuse and is directed toward relevant stakeholders in a routine clinical context. We need dediagnosing to remove diagnoses that do not reduce persons’ suffering and to make them less ill.
8. Contributors and sources
Author ML has many years of experience as a clinical pharmacist working in hospital wards, conducting medicine reviews, including deprescribing, as one of the work tasks. She has a PhD in clinical pharmacy from 2019. Author BMH is a professor in philosophy of medicine and ethics and has worked extensively with fundamental issues and concepts in health care, such as disease, diagnosis, futility, and overdiagnosis. ML had the idea of the article and made the first draft. Both authors have contributed substantially to the content of the article and several revisions. ML has made Box 2 and 3, Table 2 and Fig. 2, while BMH has made Box 1, Table 1, and Figs. 1 and 3. The final version of the article has been approved by both authors and both are guarantors of the article.
Declaration of Competing Interest
We certify that there is no actual or potential conflict of interest in relation to this study, and there are no financial arrangements or arrangements with respect to the content of this viewpoint with any companies or organizations.
Acknowledgments
We are most thankful to several anonymous clinicians whose wise comments have contributed to the improvement of the article.
Patient involvement
We are most thankful to members of two patient organisations who have generously provided comments and important viewpoints.
Data sharing statement
All data are available in the paper.
References
Scott I.A.
Hilmer S.N.
Reeve E.
Potter K.
Le Couteur D.
et al.
Reducing inappropriate polypharmacy: the process of deprescribing.
Health Services and Delivery Research. Decommissioning health care: identifying best practice through primary and secondary research – a prospective mixed-methods study.
Health Serv Deliv Res.2017; 5 (https://doi.org/10.3310/hsdr05220)
Nuland S. (2014) How we die: reflections on life's final chapter. New York, NY: Knopf; 1994, here quoted from Graber M.L., Plebani M. Diagnosis: a new era, a new journal. Diagnosis (Berl) 1: 1-2.
Do combined pharmacist and prescriber efforts on medication reconciliation reduce postdischarge patient emergency department visits and hospital readmissions?.
Strauss A Unending work and care. 1998, here quoted from Duguay C., Gallagher F., Fortin M. The experience of adults with multimorbidity: a qualitative study.
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.
A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review.
00261-2&id=gr1.jpg){kind=link}
00261-2&id=gr2.jpg){kind=link}
00261-2&id=gr3.jpg){kind=link}