Diagnostic Reasoning and Medical Overuse with Deborah Korenstein, MD

The External Medicine Podcast

This conversation was recorded on June 7th, 2021. In this interview, we talk with Deborah Korenstein, MD, about medical overuse and overdiagnosis. We discuss her April 2021 publication in JAMA Internal Medicine, the Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing as well as the diagnostic process, the teachability of diagnostic reasoning, cognitive biases, and other topics.
Who is Deborah Korenstein?

Dr. Deborah Korenstein is Chief of the General Internal Medicine Service at Memorial Sloan Kettering Cancer Center in New York. Her clinical work focuses on care to adult survivors of childhood and other high-risk cancers. As a researcher and an educator of physicians in training, she is interested in improving the value of care while minimizing unnecessary and potentially harmful tests and treatments.

To learn more about mitigating medical overuse, check out the ABIM Foundation's Choosing Wisely campaign and Dr. Korenstein's project Testing Wisely.
Factoids:

In this week's episode, we list some factoids on the overprescription of antibiotics for viral URIs, the incidence of incidentalomas, and the detection of PE with high resolution CTA. If you'd like to read the articles from which these factoids were taken, check them out below:

1. 2019 Update on Medical Overuse: A Review in JAMA Internal Medicine

Highlights:

• Procalcitonin does not affect antibiotic duration in patients with lower respiratory tract infection (4.2 vs 4.3 days)
• Incidentalomas are present in 22% to 38% of common magnetic resonance imaging or computed tomography studies
• 9% of women dying of stage IV cancer are still screened with mammography
• Clinics commonly overprescribe antibiotics (in 39% of all visits, patients received antibiotics)
• State medical liability reform was associated with reduced invasive testing for coronary artery disease, including 24% fewer angiograms

2. Overdiagnosis in primary care: framing the problem and finding solutions in BMJ (2018)

Highlights:

• Overdiagnosis is defined as the diagnosis of a condition that, if unrecognized, would not cause symptoms or harm a patient during his or her lifetime
• Overdiagnosis can harm patients by leading to overtreatment (with associated potential toxicities), diagnosis related anxiety or depression, and labeling, or through financial burden.
• Many entrenched factors facilitate overdiagnosis, including the growing use of advanced diagnostic technology, financial incentives, a medical culture that encourages greater use of tests and treatments, limitations in the evidence that obscure the understanding of diagnostic utility, use of non-beneficial screening tests, and the broadening of disease definitions.

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What is the External Medicine Podcast?
The External Medicine Podcast explores some of the most exciting ideas in medicine. Co-hosted by Daniel Belkin, MD, and Mitch Belkin, MD.

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