1 Moving beyond flexner: evolving medical education to stop promoting overdiagnosis

Abstract

The current paradigm for making medical care decisions often leads to overdiagnosis, overtreatment, and profound wasting of resources. It was introduced with the overhaul of medical training in the United States and Canada following the report to The Carnegie Foundation by Abraham Flexner in 1910. This report ushered in a rational approach to medical care, with decisions made based on careful understanding of pathophysiology rather than on empirical observation. An evidence-based medicine approach to decision making challenges this tradition, requiring decision making to be based on empirical research results of demonstrated clinical benefit rather than on pathophysiologic reasoning. As a result, evidence-based medicine requires a paradigm shift: Instead of relying on ‘what ought to work,’ it requires identifying ‘what has been shown to work.’ This reorientation requires clinicians to appreciate the role of probability in medicine. It is only with understanding and appreciating roles of uncertainty and probability that the various interventions that lead to overdiagnosis and overtreatment can be dropped from one’s practice. However, for many clinicians inculcated into bio-mechanical reasoning to make medical decisions, embracing outcomes-based, probabilistic thinking requires a transformation in their worldview. In this seminar, we will discuss the concept that probabilistic thinking is required to embrace evidence-based medicine, with the goal of moving beyond Flexner to evolve education to stop overdiagnosis and overtreatment decisions at their root. After this brief introduction to the concepts, we will divide attendees into small groups to address five issues where embracing probabilistic thinking can address issues of overdiagnosis, overtreatment, and overuse, including: 1) ‘Action Gone Awry’ (harming people with the best of intentions); 2) ‘Innocent Bystanders’ (people affected by false positive results); 3) ‘Creating the Worried Well’ (the effect of labeling); 4) ‘The Butterfly Effect’ (the unanticipated and unintended consequences of our actions); and, 5) ‘Out of Oz’ (the lure of wishful thinking).