1 00:00:00,480 --> 00:00:03,870 Hi, everybody. Well, my name is Carl Hannigan. 2 00:00:04,140 --> 00:00:11,549 I know some people and I know some of you are on the diagnostic course and some of you have just walked in off the street. 3 00:00:11,550 --> 00:00:15,350 Is that correct? Yeah. Are you in the right place? Yes. 4 00:00:15,700 --> 00:00:15,870 Alright. 5 00:00:17,970 --> 00:00:26,010 I've been doing diagnostic work for about 20 years ago and I put this title out and then you said on the Twittersphere and somebody last week went, 6 00:00:26,160 --> 00:00:29,160 Oh, why do we need to talk about diagnostic reasoning? 7 00:00:29,400 --> 00:00:35,729 We thought it all that out in the nineties, didn't we? And at that point, oh my gosh, that's really interesting. 8 00:00:35,730 --> 00:00:39,900 Somebody believes that most of diagnostic reading is sorted in the NHS. 9 00:00:40,680 --> 00:00:46,050 I very rarely meet somebody in clinical practice who would understand what the [INAUDIBLE] they're doing. 10 00:00:47,700 --> 00:00:51,170 All right. And I'm going to explain to you why. All right. 11 00:00:51,180 --> 00:00:53,550 I've got loads of examples, but I'm only going to give you a few. 12 00:00:55,080 --> 00:01:03,540 I was in New York when I got an invite to an overdiagnosis conference and they said, We want you to do the keynote speech in Barcelona. 13 00:01:03,790 --> 00:01:08,820 Oh, that's really neat. And I often thought when you were in New York, you know, the signposts were caution. 14 00:01:09,480 --> 00:01:11,010 It was somewhat to do with the traffic. 15 00:01:11,010 --> 00:01:18,390 But actually what it was really to do was, is this van, I think, where you can have a CT scan on the side of the road. 16 00:01:19,110 --> 00:01:26,070 And if you go in New York, you can have the road to early detection and you can pay on the side of the road and get a CT scan. 17 00:01:26,580 --> 00:01:31,860 Well, good idea. Scan the brain for free or for a few hundred dollars tomorrow. 18 00:01:32,700 --> 00:01:36,840 And on the way home I started to realise all this stuff is emerging everywhere. 19 00:01:37,980 --> 00:01:42,210 You get these adverts all the time on June £20 you can have a genetic test. 20 00:01:42,450 --> 00:01:48,660 In fact, only a few weeks ago you said the NHS is going to do genetic tests for everybody and you're going to pay us. 21 00:01:49,290 --> 00:01:55,979 Fantastic. And then when I got home I started to realise I'm at the right age. 22 00:01:55,980 --> 00:02:00,450 So there are some people in the room who are a bit older than me and the young people. 23 00:02:00,450 --> 00:02:05,399 This doesn't apply to you yet, but when you hear about 40, you start to get letters in the post. 24 00:02:05,400 --> 00:02:10,440 Don't you like this? An urgent message about your eye examination. 25 00:02:10,440 --> 00:02:17,910 It's two years since your last examination, and I have a family history of glaucoma. 26 00:02:18,840 --> 00:02:23,050 Anybody else having family history? What does that entitles you to know? 27 00:02:23,310 --> 00:02:31,620 ENTITLES you to a free annual NHS check? Does anybody realise that spectators is part of the NHS, the NHS organisation? 28 00:02:32,190 --> 00:02:35,190 And I go in there and they send me letters like this. 29 00:02:35,670 --> 00:02:40,440 You must come now. It's urgent and so everybody is over. 30 00:02:40,450 --> 00:02:47,550 Once you hit 40, if you've got a family history of glaucoma, you will get an invite annually to come for an eye test. 31 00:02:49,080 --> 00:02:56,520 Now, as Professor of VBM, what would you expect? I'll just go along and do my test or think I ask questions about is that appropriate? 32 00:02:57,840 --> 00:03:01,740 Okay, now here's the evidence on this. 33 00:03:02,430 --> 00:03:08,430 This is the health technology assessment for the cost effectiveness of screening for open angle glaucoma. 34 00:03:09,480 --> 00:03:15,870 And here's what it says. So there are only two trials on this front. 35 00:03:15,870 --> 00:03:19,679 What is it you think for a problem where you're going to go blind? 36 00:03:19,680 --> 00:03:21,450 This would be a really important issue. 37 00:03:22,920 --> 00:03:33,900 And these words I put in green because I think extrapolating and assuming can be translated in to we're making it up here. 38 00:03:34,650 --> 00:03:44,790 So if you if you are the people at risk and you have a positive screening test, then basically you're going to be committed to the lifelong treatment. 39 00:03:45,270 --> 00:03:53,610 And we think if you do that, on average, you'll go blind less by about ten years, 23, 25, as opposed to 35. 40 00:03:54,690 --> 00:04:00,060 But look, prevalence would have to be about 3 to 4% in 40 rolls. 41 00:04:01,740 --> 00:04:06,840 And if it was a screening interval of ten years, it would approach cost effectiveness. 42 00:04:08,790 --> 00:04:15,929 So if I go at 40 and my risk is 3 to 4%, then it should have me test at 40 and 50. 43 00:04:15,930 --> 00:04:19,770 I should get me in five, but then it would be cost effective. 44 00:04:21,870 --> 00:04:27,149 But what it says not effective. So I think that's really interesting. 45 00:04:27,150 --> 00:04:33,750 So we put in so if you go to the US Preventative Services Task Force, the people in America who do the guidelines, 46 00:04:34,080 --> 00:04:42,870 this is what they say they have not recommended for or against routine glaucoma screening for adults based on the evidence that would make sense. 47 00:04:44,160 --> 00:04:49,650 Anybody like to disagree with them? Anybody work for NHS choices in the room? 48 00:04:49,920 --> 00:04:53,040 Because if you do, that's what it says. 49 00:04:55,410 --> 00:04:59,850 It is important to have regular eye tests. So. 50 00:05:00,060 --> 00:05:04,920 We in the NHS, when people say to me we need, we need more funds. 51 00:05:06,930 --> 00:05:12,030 The first thing I say is more is not necessarily better. It doesn't translate into more health. 52 00:05:12,300 --> 00:05:16,200 And what we mean by cost effective is do the benefits outweigh the harm? 53 00:05:17,340 --> 00:05:24,210 Because if you pick up a disease early, if it's a false positive, you're committing somebody to 30 years of treatment. 54 00:05:24,510 --> 00:05:28,710 But something that would not of they derived any outcomes whatsoever. 55 00:05:29,100 --> 00:05:35,670 So you introduce you know, you have to think about the issues of medicalizing somebody for 30 plus years. 56 00:05:36,450 --> 00:05:41,609 You walk in on the street, you're 40 years old. And some somebody goes, you have an eye problem. 57 00:05:41,610 --> 00:05:44,880 That means you're going to go blind. Unless that's not true. 58 00:05:45,420 --> 00:05:49,980 And so these statements are unhelpful and incorrect. 59 00:05:50,400 --> 00:05:52,890 Put this on NHS charities. 60 00:05:54,450 --> 00:06:04,590 So well, the thing is, if you look at the diagnostic evidence, okay, you have two terms, your sensitivity, annual specificity. 61 00:06:05,760 --> 00:06:09,920 Yep. And all the people on the course have got them committed in their mind. 62 00:06:09,930 --> 00:06:13,470 So by Thursday, when I come back to you, you're going to be like this. 63 00:06:14,970 --> 00:06:19,920 The proportion of people with disease who test positive is the sensitivity. 64 00:06:20,070 --> 00:06:25,590 And you want that to be really high in the proportion of people without the disease who test negative. 65 00:06:25,650 --> 00:06:34,500 You also want that to be really high. So the perfect test has 100% sensitivity and 100% specificity, intraocular pressure. 66 00:06:34,770 --> 00:06:37,829 That's when they put some in and test the pressure in your eyeball. 67 00:06:37,830 --> 00:06:43,530 And if it go though, you've got you're at risk of glaucoma. If it gets too high, then you do the treatment. 68 00:06:43,560 --> 00:06:46,800 So this is above a certain pressure. Okay. 69 00:06:48,030 --> 00:06:52,260 So we go back to the 5% prevalence. 70 00:06:52,710 --> 00:06:56,610 I'm going to walk you through this. This is a bit now where you go into a clinical session. 71 00:06:56,610 --> 00:07:00,570 I've done this with radiologist, consultant, the lot that completely lost. 72 00:07:00,990 --> 00:07:08,590 What this completely underpins your rational thinking. And if you assume a 5% prevalence, so somebody's at risk. 73 00:07:08,610 --> 00:07:16,230 So if we assume as a 40 year old with a family history, you have about 5% chance of having glaucoma in your lifetime. 74 00:07:16,620 --> 00:07:23,009 Okay. The first thing you can do is work out some very simple things like intifadas and people, 75 00:07:23,010 --> 00:07:28,650 50 people will have the disease and 950 will not approve them. 76 00:07:29,160 --> 00:07:34,380 Very simple. Now you can start to translate from very simple pieces of information. 77 00:07:35,070 --> 00:07:46,890 If you take the sensitivity to be 90% okay, sensitivity is a proportion of people with the disease who test positive. 78 00:07:47,880 --> 00:07:53,560 How many people? Well done, Cooper. 79 00:07:53,770 --> 00:08:01,750 Well, it's not that difficult. Right. So it's pretty good, actually, if 50 people with the disease will test, but then 45 will test positive. 80 00:08:02,180 --> 00:08:06,190 Well, and we also look at the specificity. 81 00:08:06,190 --> 00:08:14,380 Amazing, 99%. So you also can say of the people without the disease, how many of them will test positive? 82 00:08:15,340 --> 00:08:18,400 Well, actually, you can get this phone number. Okay. 83 00:08:18,820 --> 00:08:24,220 And that's sort of like if you do the number, the math for it, that specificity is 90%. 84 00:08:24,470 --> 00:08:34,690 It's not 99, 90%. But let me just tell you, if you do the best positive test result, 140 people will test positive, of which only 45 have the disease. 85 00:08:35,840 --> 00:08:43,330 Yeah, that's the best result. So of everything, if you go to Specsavers have a positive test. 86 00:08:43,600 --> 00:08:47,290 There's only a warning for each month of you actually having the disease empty. 87 00:08:47,310 --> 00:08:52,060 All of the people will have a job for the next 30 years as a false positive. 88 00:08:53,470 --> 00:09:00,820 But that's the best ever it can be that taking the best research, the biased of if you look at the stuff when you go for the worst case scenario. 89 00:09:01,780 --> 00:09:06,580 Yeah. This is what it looks like for the worst case scenario. 90 00:09:09,760 --> 00:09:14,230 Yeah. If you look at the research. 91 00:09:14,980 --> 00:09:23,350 One in 30 chance of you actually having the disease. And so we accept this really poor quality research all the time. 92 00:09:25,660 --> 00:09:31,000 And to me is understanding the reasoning suggests we have a problem. 93 00:09:32,800 --> 00:09:34,120 The studies are no good. 94 00:09:34,540 --> 00:09:41,230 Even if you take the best case scenario, you've got a one in three chance of it being correct and a two in three chance of it being incorrect. 95 00:09:41,800 --> 00:09:45,970 So for every three people diagnosed, two people will be false positive. 96 00:09:46,600 --> 00:09:52,900 Happy with that? If you assume and take the best possible study result, which that's what you do, 97 00:09:52,910 --> 00:09:58,240 critical appraisal and you say there's a range of studies, so maybe we'll take the midpoint, you have to make some decision. 98 00:09:58,420 --> 00:10:03,520 But if you look at the worth type of results, oh my God, he committed to 30, 99 00:10:03,520 --> 00:10:12,670 40 years of treatment and which 97 people out of 100 won't have the disease and only free will and you'll never know the answer. 100 00:10:12,700 --> 00:10:16,140 Nobody will know the answer because we don't do the research to follow people. 101 00:10:16,750 --> 00:10:22,600 So it's not surprising. But this is why we do it, because you get these personal accounts all the time. 102 00:10:23,740 --> 00:10:32,860 When I got my test just in time and I got the treatment and therefore I've been saved, you know, and that's the sort of where health care is. 103 00:10:36,040 --> 00:10:41,810 So if you were me, what would you do? Would you go for your annual screening test if you knew the information like that? 104 00:10:42,100 --> 00:10:45,430 What would your decision be? Would you go? 105 00:10:45,700 --> 00:10:48,790 Never again. We every five years. 106 00:10:50,200 --> 00:10:53,490 Would you go every ten years? Come on. This is evidence based practice. 107 00:10:53,500 --> 00:10:59,350 What you. Egan, advise me based on the evidence, what the USPSTF said, what the evidence shows you. 108 00:11:00,580 --> 00:11:06,250 We can't in practice. Evidence based practice. Go. I know if you want to go to Specsavers. 109 00:11:06,580 --> 00:11:12,550 But do you mind if we do a study before we come? No, I'm telling you, I'm looking for you based on this information. 110 00:11:12,820 --> 00:11:22,440 Well, for showing you that the best evidence assumes if I'm treated and I have to make it up because the trial is only 2 to 3 years, 111 00:11:22,450 --> 00:11:28,090 if it's somewhere between 25 and 35 years in the delay in getting glaucoma. 112 00:11:28,120 --> 00:11:34,600 So it's not it's not yes or no. It's just a delay because the pressures will go up and up and you delay in that process. 113 00:11:35,230 --> 00:11:42,310 However, if I assume the best test, then there's a two in three chance, some false positive. 114 00:11:42,400 --> 00:11:48,400 If I get a certain positive diagnosis, the US Preventive Task Force says Don't bother. 115 00:11:48,430 --> 00:11:52,670 NHS says go regular and it looks like cost effective. 116 00:11:52,760 --> 00:11:55,780 Says it's about ten years. If I have a four or 5% risk. 117 00:11:56,440 --> 00:12:00,160 So what we're going to do, you might say I'll go ten you. 118 00:12:01,150 --> 00:12:04,870 I've had my one test at 40, I've now been at 50. 119 00:12:06,010 --> 00:12:12,670 So it's the same question you could ask yourself the evidence based question of going, What should I do in a screening world? 120 00:12:13,480 --> 00:12:19,570 But what I'm putting to you guys right now is how little people ask these sorts of questions in health care, 121 00:12:20,110 --> 00:12:25,600 whether it's people in the NHS, it's commissioners, whether it's doctors, clinicians, just go, 122 00:12:25,990 --> 00:12:32,740 I'm going to go and have my test because I got a letter without understanding what the potential benefit and harms are. 123 00:12:32,920 --> 00:12:38,440 Now when you think about it, this not everywhere is when I got another appointment invitation. 124 00:12:38,980 --> 00:12:43,390 This is to a health screening clinic at the Kissan Stadium. 125 00:12:44,050 --> 00:12:49,610 Wonderful. Look at this. Why have I been invited? We write to a small number of people. 126 00:12:49,630 --> 00:12:56,260 How lucky am I? Yeah. We encourage you to compare the content and quality of our screening with BUPA. 127 00:12:56,560 --> 00:12:59,800 Our screening is £129 cheap with chips. 128 00:13:00,580 --> 00:13:08,350 Okay. However, if you go for the BUPA health check that includes all these essential health checks, it would be £424. 129 00:13:09,640 --> 00:13:11,920 So this stuff is invading everywhere we go. 130 00:13:14,920 --> 00:13:24,430 But going back some time, this is a paper which involved Brian Haines and Dave Sackett, which I referred to a book in 1978, which basically said, 131 00:13:25,150 --> 00:13:33,370 we knew if you go into industrial settings in the seventies and can flim and explore people's diagnoses of hypertension, 132 00:13:34,060 --> 00:13:42,460 you definitely will increase their absenteeism. You will make sure they're more anxious and depressed and they have more psychological problems. 133 00:13:42,470 --> 00:13:46,330 So we don't understand what is the important outcome. 134 00:13:47,470 --> 00:13:56,800 We have to have these trade off. Do you really want to know at 40 you might just die at some point on the fact you will die at some point? 135 00:13:57,880 --> 00:14:05,980 Or would you like me to say, actually, we can tell you exactly the day and what it is and what you have to reduce your risk by all the time. 136 00:14:06,580 --> 00:14:10,540 And in doing that won't harm through. We introduce into. On it for me to think about that. 137 00:14:10,870 --> 00:14:17,050 So here's another one. I don't know anybody's come across that anybody ever done any depression screening? 138 00:14:18,850 --> 00:14:22,150 You've done it as part of your job or have you done it on yourself? 139 00:14:23,680 --> 00:14:26,800 Yeah, well, I'd recommend this. We do these scores all the time. 140 00:14:27,220 --> 00:14:31,270 Q 93 is a health questionnaire for depression. 141 00:14:31,930 --> 00:14:41,319 And what happens is these measures turn out of measures in research, because there are nice way of saying we did a treatment and we did the Q nine. 142 00:14:41,320 --> 00:14:49,630 They've got some face validity and we showed the difference between Treatment A and B and then we go, Oh, actually we use it as a diagnostic criteria. 143 00:14:50,950 --> 00:14:54,639 So look what happened. So here's the nine question. 144 00:14:54,640 --> 00:15:01,360 So I put these questions to myself, okay, so little interest on pleasure in doing things. 145 00:15:01,510 --> 00:15:04,659 On several days I was feeling a bit unwell when I did this. 146 00:15:04,660 --> 00:15:10,110 I had the flu, I was feeling a bit down and it was like the week after Christmas. 147 00:15:10,120 --> 00:15:14,410 It didn't say when it was, you know. So I scored one feeling. 148 00:15:14,680 --> 00:15:18,310 I scored for trouble. Falling asleep, staying asleep or sleeping too much. 149 00:15:19,240 --> 00:15:28,270 Nearly every day I have problems falling asleep and a problem staying asleep and it pretty much is quite common and myself afraid, 150 00:15:29,500 --> 00:15:33,130 feeling tired or having little energy. Anybody in the room feel a bit like that? 151 00:15:33,460 --> 00:15:40,390 I feel like now more than half the days you can see poor appetite or overeating. 152 00:15:41,560 --> 00:15:46,150 I overeat a lot in the evenings and I have a poor appetite in the mornings and I 153 00:15:46,150 --> 00:15:50,440 have trouble concentrating and things such as reading the newspaper or watching TV. 154 00:15:50,830 --> 00:15:54,160 If that was my children, they'd be every day because they're always on their iPhone. 155 00:15:55,210 --> 00:16:04,300 And so my score was about 5 to 9. I have minimal symptoms, but I need support and education to call it worth returning one month. 156 00:16:05,620 --> 00:16:09,700 Okay, I have a provisional diagnosis. I'm nearly another point. 157 00:16:09,910 --> 00:16:16,360 I've got mine and depression now is you've mentioned it like repeat the test. 158 00:16:16,360 --> 00:16:20,980 I might do it again today. The score might be four. So there's no measurement about variation. 159 00:16:21,130 --> 00:16:27,850 On another day I could score ten. I suspect everybody in this room on a day, on a bad day could score ten. 160 00:16:29,980 --> 00:16:34,010 You get a rejection from the BMJ. You're like a ten, right? 161 00:16:35,590 --> 00:16:41,440 But it's interesting when you look at the evidence of the false positives and the false negatives and looking at the diagnosis. 162 00:16:42,220 --> 00:16:46,090 Yeah. And what's really interesting, 163 00:16:46,090 --> 00:16:53,710 if you up the biggest factor in these studies that says what makes a difference to you getting a diagnosis of depression or not. 164 00:16:54,070 --> 00:17:00,430 Yeah. So the you've got depression, you get a diagnosis of depression or you haven't got depression, but you do. 165 00:17:00,880 --> 00:17:07,990 Yeah, it's familiarity that basically the biggest thing you can do is if you turn 166 00:17:07,990 --> 00:17:12,370 up at your general practitioner enough and so you're fed up with the world, 167 00:17:12,550 --> 00:17:19,209 you will get a label of depression irrespective of whether you've got it or not, because at some point the variation will. 168 00:17:19,210 --> 00:17:22,750 [INAUDIBLE] ask you some of these questions. Do you feel tired? Yes. 169 00:17:23,530 --> 00:17:26,890 Do you feel like lacking concentration? Yes. That's why I'm here. 170 00:17:27,580 --> 00:17:30,700 Are you having poor appetite? Of course I am. You have depression. 171 00:17:31,450 --> 00:17:34,780 And the biggest factor is how many times you turn up. Isn't that interesting? 172 00:17:36,280 --> 00:17:39,820 And so we have huge number of people who are mislabelled. 173 00:17:40,060 --> 00:17:49,600 And that's why we end up with issues like this of doubling in a decade and features like this, the numbers going through the roof. 174 00:17:49,600 --> 00:17:56,190 And then this is open prescribing of what some people are doing and this huge variation in treatment and diagnoses across the whole juncture, 175 00:17:56,680 --> 00:18:07,000 fourfold variation sometimes in diagnoses and and huge variation in prescriptions of about three fold variation in prescriptions because nobody 176 00:18:07,300 --> 00:18:18,370 understands variation how many times you think you'd have to repeat that measure for it to become stable and you understand what's going on. 177 00:18:18,940 --> 00:18:22,989 Now, we understand that in blood pressure, because if you do self-monitoring, 178 00:18:22,990 --> 00:18:26,890 the blood pressure monitoring, they tell you you have to do it for seven days. 179 00:18:28,270 --> 00:18:35,440 And the blood pressure will vary. Even if you need to go to the toilet, it will go before it will go up by 20 millimetres of mercury. 180 00:18:35,620 --> 00:18:38,140 If you have a cup of coffee, it will go up. Oh, we think varies. 181 00:18:38,350 --> 00:18:42,970 And so sometimes we say ambulatory blood pressure because we don't understand variation. 182 00:18:43,960 --> 00:18:49,660 We give you a label on a single measure of depression, which is not what we should be doing. 183 00:18:50,800 --> 00:18:56,200 So there's a whole wave of research to start to look at this variation in practice. 184 00:18:56,200 --> 00:19:04,930 And at one thing, to have a read of which is available online is this atlas of variation in NHS diagnostic services. 185 00:19:05,740 --> 00:19:15,480 Unbelievable. The variation that exist. Cannot be explained by patient need, completely lacking evidence based guidelines. 186 00:19:15,780 --> 00:19:19,350 This type of variation of all imaging tests and blood tests. 187 00:19:20,010 --> 00:19:24,120 So one of the things I've had is as a student working with me, Jack O'Sullivan, 188 00:19:24,720 --> 00:19:29,730 who basically has come into the field and we've been looking at these things about rising number of tests. 189 00:19:31,290 --> 00:19:36,300 And this is what it looks like, the temporal trends in total testing from UK primary care. 190 00:19:37,050 --> 00:19:41,670 So look, this is test ordered per 10,000 person years. 191 00:19:41,740 --> 00:19:50,070 Yes. So this is 10,000 people for one year? Yep. In 2000, it was about 14 to 15000 tests. 192 00:19:50,460 --> 00:19:54,630 So one and a half test per person. Everybody happy with them? 193 00:19:55,380 --> 00:20:00,680 Some get more, some get less. But where it is now, 50,000 per 10,000 years. 194 00:20:00,690 --> 00:20:03,780 So on average, everybody gets about five tests per year. 195 00:20:06,120 --> 00:20:10,710 Now, I don't know what you think about that, but that's a huge increase, isn't it? 196 00:20:12,000 --> 00:20:17,700 Yeah. If you think about somewhere like Oxford City, that's about 170,000 people. 197 00:20:18,120 --> 00:20:21,570 So it's 50,000 times about 70. 198 00:20:22,920 --> 00:20:23,220 Yeah. 199 00:20:23,490 --> 00:20:29,910 And they can go look at the paper and it shows you some people are getting an inordinate amount of tests, but actually it's been a huge increase in. 200 00:20:29,910 --> 00:20:33,670 That's less than full of tests. Some tests are much greater. 201 00:20:33,690 --> 00:20:35,540 I'll show you something like cholesterol has gone up, 202 00:20:35,550 --> 00:20:42,210 but there are all sorts of old tests like vitamin B12 have gone through the roof and even in children increasing. 203 00:20:42,510 --> 00:20:47,790 So across the board, it's going up. Now, anybody who is looking at that would go bloody, oh, 204 00:20:47,790 --> 00:20:56,790 you better be preparing for them in the estimated time that it takes the GP just to look at the tests at this 205 00:20:56,790 --> 00:21:04,590 point we reckon should take them 2 hours a day just in responding to the test they now get in practice, 206 00:21:05,310 --> 00:21:08,530 which is impossible on top of all the other work they get. 207 00:21:08,550 --> 00:21:13,980 So basically a lot of this stuff is never getting looked at and here's what it looks like just for imaging. 208 00:21:13,980 --> 00:21:18,480 I'm just going to focus on imaging. Okay. Need to finish imaging so you all have to think. 209 00:21:19,170 --> 00:21:24,540 Yeah, I'm going to give you. So there's been about 116% increase in youth, about doubling. 210 00:21:25,890 --> 00:21:30,000 Right. So here's equate. All right. You write these down. 211 00:21:30,000 --> 00:21:33,570 But you have to you have to be honest. Okay. Because we'll come back to the answer. 212 00:21:33,600 --> 00:21:40,410 So, look, the five tests, you got to pick one of five going to go five different shapes. 213 00:21:40,620 --> 00:21:46,790 Right. So you want to commit to memory. I could have made you write it down, but I haven't got a probably so with no chance. 214 00:21:46,800 --> 00:21:50,490 Alright. So I'm going to come back. So that's sheet one, one of them. 215 00:21:50,490 --> 00:21:57,569 Is that right? This is test ordering for imaging in primary care. 216 00:21:57,570 --> 00:22:05,010 So this is c.t brae lumbar spine mri, chest X-ray, pelvic ultrasound, lumbar spine X-ray. 217 00:22:05,580 --> 00:22:12,840 Happy with that? So two X-rays, an ultrasound, a spine, MRI, and a brain. 218 00:22:13,560 --> 00:22:16,860 I'm going to come back and then I'm going to have you, but it's going to let you see the lot and then walk with it. 219 00:22:16,890 --> 00:22:20,160 That's number two. That's number three. 220 00:22:20,160 --> 00:22:29,010 Just a gradual rise. And before how much change and number five goes up and jumps down. 221 00:22:29,490 --> 00:22:33,400 Okay. Right. You ready? Right here. 222 00:22:33,780 --> 00:22:38,009 Who's going to go? Who's got anything sensible to think? What counts for this range? 223 00:22:38,010 --> 00:22:49,660 Anybody go, what's up? Just that you are sorry for that C.T. brain. 224 00:22:51,010 --> 00:22:54,660 Goes up a lot. Goes up a lot. Stop. 225 00:22:54,830 --> 00:23:00,010 And we know this is no artefact and then continue thriving. So there's something happening, isn't there? 226 00:23:01,360 --> 00:23:04,389 This is probably the advent of city with a real change. 227 00:23:04,390 --> 00:23:10,420 When money came in to the NHS in 2000, people parity then huge increase stabilisation, but then it's going again. 228 00:23:12,580 --> 00:23:21,100 So this is the things we're looking into. This is more money coming in, this is probably normality and then this is possibly guidelines coming back. 229 00:23:23,500 --> 00:23:30,340 What's that one? Do you think this is really just a general increase all the time, going from about 200 to about 400. 230 00:23:30,340 --> 00:23:35,169 So about doubling in numbers. Yeah. 231 00:23:35,170 --> 00:23:40,120 Well, don't just x ray. Very interesting. So who said chest X-ray photo? 232 00:23:40,300 --> 00:23:43,740 So that gentleman in that lady there. What? What for? Accounting for that. 233 00:23:43,850 --> 00:23:46,970 Keep going up. Quite. 234 00:23:47,050 --> 00:23:55,629 Remember, this is from primary care test order. Now, if did change their guidelines, they said basically in terms of the cancer referral guidelines, 235 00:23:55,630 --> 00:23:59,200 if you've got a couple for three weeks, you should send people for a chest X-ray. 236 00:23:59,500 --> 00:24:03,070 No evidence for that being a benefit but nice guideline said around about here. 237 00:24:03,670 --> 00:24:09,969 People for because we're concerned that you might have an underlying malignancy it's 238 00:24:09,970 --> 00:24:13,570 not needed in the it's not needed in the diagnosis and treatment of pneumonia. 239 00:24:14,350 --> 00:24:19,390 So what's the accounting for this general? Right. We know nicely, but it can't account for everything. 240 00:24:20,260 --> 00:24:25,540 We don't know whether it's people coming out trying different and thinking because the thing is, if you have pneumonia. 241 00:24:25,900 --> 00:24:30,850 Yeah. And community acquired pneumonia. The chest x ray should alter my management. 242 00:24:32,830 --> 00:24:37,870 The only thing if I'm suspecting something more suspicious. And that's just it right about that one. 243 00:24:39,850 --> 00:24:45,150 Not this one. Yeah, well done. But it's a lot cheaper than it. 244 00:24:45,160 --> 00:24:50,379 What should it look like? It should look like that. 245 00:24:50,380 --> 00:24:52,960 Shouldn't it be coming down? 246 00:24:53,200 --> 00:25:02,740 We know that from about 2000 onwards, all the evidence is telling you that lumbar spine X-rays are pretty much a useless waste of time in backpay. 247 00:25:03,250 --> 00:25:09,640 And if you're going for serious pathology, you wouldn't be referring for an X-ray, would you, in the spine. 248 00:25:11,290 --> 00:25:18,660 So we can I can explain that. But I thought this would be the one that when we did it, it's going to come down here. 249 00:25:18,970 --> 00:25:26,670 But actually, as you can see, it's not much changed. Okay, sharp, rise up and down. 250 00:25:26,680 --> 00:25:31,600 You're running out of options now if you've remembered her pelvic ultrasound. 251 00:25:32,740 --> 00:25:36,790 Huge increase. Yeah, huge increase. 252 00:25:36,790 --> 00:25:40,150 And then some it's happened here where the guidelines will have changed. 253 00:25:40,300 --> 00:25:43,990 Guidelines have a huge impact. And then this is the final one. 254 00:25:44,470 --> 00:25:46,090 So there are multiple reasons, 255 00:25:46,660 --> 00:25:54,850 but isn't it worth thinking about the consequences of what we do all the time in terms of the data on diagnostic testing? 256 00:25:54,850 --> 00:26:00,490 What are we doing, what we achieving? One of the things I think I hope you can say is, oh my God, look at the amount of work we created. 257 00:26:01,810 --> 00:26:05,520 Because every time you do a test, it's not just the test is the individual. 258 00:26:05,520 --> 00:26:11,110 We have to communicate them results. Then they have to come in and have a discussion with you and then you have to do something further about it. 259 00:26:11,440 --> 00:26:15,280 I mean, any business would be going, Oh my God, this is amazing amount of work. 260 00:26:16,810 --> 00:26:20,860 We're going to expand primary care. We're going to be bigger and better. 261 00:26:20,860 --> 00:26:26,770 We're going to sell you the world. But actually what's happened is we've had less GP's in less time and this is why we've got a real strain. 262 00:26:27,430 --> 00:26:35,259 But I think this is lumbar spine is because we got direct access referral, so that's quite easy to explain, 263 00:26:35,260 --> 00:26:42,220 but it does create a huge amount of work for people who are not really that thoughtful in terms of diagnostic reasoning. 264 00:26:44,440 --> 00:26:47,509 So how did you do it? Interesting, isn't it? 265 00:26:47,510 --> 00:26:51,310 I'm doing this with a group of radiologists who they're the people who look at all these tests. 266 00:26:51,730 --> 00:26:53,260 Nobody got more than three out of five. 267 00:26:54,550 --> 00:26:59,440 And it's quite interesting because they never understood in their own organisation we should look at what we're doing, 268 00:26:59,740 --> 00:27:03,250 thinking about what what the test looked like, what's going up. 269 00:27:03,490 --> 00:27:12,130 Because as we do more tests, what happens to the, the, the, the ability of the test to determine the positive predictive value? 270 00:27:12,850 --> 00:27:18,969 What happens? It gets worse, performance gets worse because if you do more tests, the prevalence gets left, 271 00:27:18,970 --> 00:27:23,709 doesn't it, that the prevalence gets less, it gets harder to rule in and rule out. 272 00:27:23,710 --> 00:27:26,830 Disease gets much harder. 273 00:27:27,340 --> 00:27:35,260 So we have a huge problem if you're doing more and this is what what really interests me and I think later on the way you do it, 274 00:27:35,650 --> 00:27:48,550 you get something like this. Yeah, the incidence of thyroid cancer in the UK is going up and up and up and then mortality is more or less flatlining. 275 00:27:50,830 --> 00:27:54,400 So we have situations where we pick it up more and more. 276 00:27:54,790 --> 00:28:01,630 We're trying to say to people, stop sending people for ultrasound of the head and that and nothing is changing here. 277 00:28:03,520 --> 00:28:11,469 So there's a huge business in health care, in diagnostic services and technology that will offer no benefits, 278 00:28:11,470 --> 00:28:17,050 but will offer benefits to industry and the economy, 279 00:28:18,520 --> 00:28:24,339 because selling people stuff that's of no benefit to them is really important for keeping the economy going. 280 00:28:24,340 --> 00:28:28,510 And America is very good at that. But this this flat line is really interested. 281 00:28:30,640 --> 00:28:37,850 And so looking at the. So if you look at the diagnostic atlas, if you go to the Atlas of Variation, 282 00:28:38,660 --> 00:28:46,040 there currently is a 4.6 fold difference between clinical commissioning group in terms of the level of activity for CTE. 283 00:28:46,940 --> 00:28:51,440 Yeah. Nobody has a clue what should be the optimal level. 284 00:28:55,040 --> 00:28:59,690 Now in some parts of the world. Overuse is a big issue in America. 285 00:29:00,140 --> 00:29:10,220 Last time I looked at this, it was about one in every five people have a c t on an annual basis, probably about one in every four now. 286 00:29:11,780 --> 00:29:16,670 And that contributes about a radiation dose equivalent to about 1% of the cancer risk. 287 00:29:17,540 --> 00:29:19,520 So it's a huge amount of radiation. 288 00:29:19,910 --> 00:29:27,140 So not only that we talk about now trying to reduce the radiation doses about three fold variation in the radiation dose using CT scanning. 289 00:29:27,680 --> 00:29:34,339 And you've got this whole body sky screening, as I showed you, where we started, where it was emerging. 290 00:29:34,340 --> 00:29:43,490 And I think all of that's quite interesting. So I consider there are some options now for evidence based action. 291 00:29:43,760 --> 00:29:47,210 Yeah, we need pathways for diagnostics. 292 00:29:48,080 --> 00:29:52,399 It's not just you having a test. You need to know the benefits and harms. 293 00:29:52,400 --> 00:29:59,870 And the results are very simple language that explains to you if you have this test, here's what it means to you. 294 00:30:00,350 --> 00:30:06,430 And the follow on treatment is this. And I'm all right with people making decisions to have screening or not. 295 00:30:06,440 --> 00:30:10,910 That's not what I'm here about. I'm here about saying that when you do that, you should be informed. 296 00:30:14,630 --> 00:30:21,020 We need a much clearer understanding of the benefits and harms resulting from different rates of investigation. 297 00:30:21,800 --> 00:30:24,950 What does it mean in these areas where you're having more or less tests? 298 00:30:25,700 --> 00:30:32,300 What's the implications on the population? And I do think we've lost our way. 299 00:30:33,050 --> 00:30:38,080 If you go back to the literature in the seventies and eighties, you'll see audits were published in The Lancet. 300 00:30:39,470 --> 00:30:46,100 People would think they're actually doing a really good old. It was a good way of understanding what's happening in practice. 301 00:30:46,100 --> 00:30:53,509 And we've lost our way with the ability to benchmark, look at practice and consider what it is we're doing and the implications. 302 00:30:53,510 --> 00:31:00,440 And it's been downgraded of just somewhat. You do just put on your CV and once you've done it, that's it. 303 00:31:00,440 --> 00:31:06,080 But actually auditing and benchmarking is really helpful for understanding what's going on in practice. 304 00:31:08,330 --> 00:31:17,300 And then I'm going to finish just to say, thinking about what it is we communicate when we're thinking to the public about tests. 305 00:31:18,320 --> 00:31:25,520 You see this a lot. You know, we're saving lives. Put it on your list. 306 00:31:26,990 --> 00:31:31,700 The emotive messages that we put out. Yeah, that's how we sell. 307 00:31:31,700 --> 00:31:37,850 We don't tell you, actually, is the numbers and the false positive and true and explain to you what's really going on. 308 00:31:38,390 --> 00:31:45,020 And, you know, you can just have this emotive and I guess I was on the London Tube just recently 309 00:31:45,230 --> 00:31:51,120 and this was my favourite I think is I can get my screening started at just £23.50. 310 00:31:51,120 --> 00:31:58,429 It is that's on the London tube with the full set of tests that I can have today which 311 00:31:58,430 --> 00:32:02,960 have no evidence underpinning the benefits of harm for me as an asymptomatic person. 312 00:32:03,380 --> 00:32:12,830 And I think I'm going to finish here because I think when you next see an advert like this, the question you want to ask yourself is, 313 00:32:13,430 --> 00:32:22,100 do I understand or have I got any possibility of understanding the benefit and the harm for me or the individual I give this test to? 314 00:32:22,820 --> 00:32:26,030 Now, that should be mandatory in the training and in any organisation. 315 00:32:26,030 --> 00:32:33,410 If we do this test, what does it mean? How does it change our management and all of that's missing now? 316 00:32:34,250 --> 00:32:40,639 And the problem is in some organisations I go into, we have also lost our way because the health system won't back people up. 317 00:32:40,640 --> 00:32:46,340 So they just say, I'm testing just in case. Well, if you're doing that, you don't need doctors. 318 00:32:47,060 --> 00:32:52,820 You just test everybody to come through the door to screen a CT scan and you walk through the door you're in. 319 00:32:54,190 --> 00:33:03,229 So I think I ask, why is it so challenging to get reasoning and diagnostics over to people? 320 00:33:03,230 --> 00:33:09,950 I'm not sure. But it's one of these things in the advent of knowledge that we should have a revolution in understanding. 321 00:33:10,730 --> 00:33:16,760 Otherwise, we are going to blow everybody's budget in health care really quickly, and we're already doing that. 322 00:33:17,810 --> 00:33:18,560 Thank you very much.