Seminar to put health system under scrutiny
A medical seminar aims to render the Island’s health system more effective by “unifying us around the philosophy and practice of evidence based medicine”, according to chief medical officer Cheryl Peek-Ball.
The symposium for healthcare professionals, to be held on Saturday, was called by a round table of the Island’s leading healthcare organisations, and has been a year in the making.
“It was clear that among the things we would need in place for a quality healthcare system would be a system of clinical guidelines, particularly for chronic disease, to ensure best practices,” Dr Peek-Ball said.
Guidelines used by the United States Preventive Service Taskforce have been widely agreed upon as “reasonable for the Island”, she said, although they are not to be imposed as law.
“Enforcement is not something I can envisage,” she said. “This is for the encouragement and education of practitioners as well as the public.”
Asked if the guidelines had any link to the contentious move to introduce medical pre-certification — aimed at cutting down on excessive diagnostic testing — Dr Peek-Ball said: “No, this isn’t related to that or any other particular policy. It’s about improving medical practices and quality of care.”
Overseas speakers Michael Lefevre and Gilbert Welch will address Saturday’s seminar, which convenes at the Bermuda Underwater Exploration Institute.
Dr Lefevre, medical director at the University of Missouri’s department of family medicine, is the immediate past chairman of the US Preventive Service Taskforce.
Explaining the guidelines, Dr Lefevre said: “I think that first and foremost it’s about changing the culture — it is about accepting that screening can be good but that it is not always good; it can always do harm, and we should screen when we have evidence that says, across the population we screen, that we can do more good than harm.”
He will speak on screening for breast, cervical and colorectal cancer, as well as vitamin D deficiency, chronic kidney disease, osteoporosis, abdominal aortic aneurysm, HIV and Hepatitis C.
“Screening is when you take somebody who has no symptoms or signs of disease, and you go looking for it,” Dr Lefevre explained.
“Abdominal aortic aneurysm is a good example; there is a recommendation of screening and to not screen.”
Men aged 65 to 75 who have been smokers constitute the highest risk group and are recommended for screening. Women who have never smoked are at low risk.
“The limited data we have does not show benefit for them,” he said. “Screening would do more harm than good.”
Turning to diabetes, a chronic disease rampant in Bermuda, Dr Lefevre said: “The Task Force does have draft recommendations on the table that support screening for diabetes, but interestingly enough the evidence we have found really more strongly supports finding people who are at risk and getting some behavioural change that would prevent the development of diabetes — as opposed to finding evidence that if we detect it early that may change outcomes.”
Screening for chronic illness is a question of “who and how often”, he said.
Overuse of screening arises from “a strong belief in technology — that doing more can only do more good”. There is also a profit motive in the US for companies supplying services, and a fear of litigation on the part of physicians. Evidence-based guidelines focus on “reviewing the literature to see what the science tells us about the benefits and harms”, Dr Lefevre explained.
The other speaker coming to the Island, Dr Welch, is a general internist at White River Junction, Vermont, and professor of medicine at the Dartmouth Institute for Health Policy and Clinical Research.
Over-diagnosis refers to “making diagnoses in people never destined to develop symptoms”, Dr Welch said — identifying diseases that don’t matter to the patient.
“South Korea, in the last 15 years, has experienced a 15-fold increase in thyroid cancer diagnoses,” Dr Welch said. “It’s not an epidemic of the disease but an epidemic of diagnosis.”
While all technically have the disease, the death rate from thyroid cancer “has not budged”, he said: not all types of thyroid cancer represent a serious threat to the patient.
Citing another example, he said: “Most men die with prostate cancer, but not from it — which is not to say there aren’t aggressive forms.”
“There’s an idea that earlier is always better, and a failure to understand that we all harbour abnormalities,” said Dr Welch.
He added: “Physicians also feel we are punished for under-diagnosis and never punished for over-diagnosis.”
The symposium, which runs from 8am to 1pm, is for healthcare guests only. To register, contact Scymone Devent at firstname.lastname@example.org.