“Anno 2024 GPs are not a part of the solution of how to get a healthy planet and healthy people”. Interview with John Brodersen, EUROPREV’s chair
To most people, including physicians and some GPs, it is counterintuitive that prevention can do more harm than good.
AI and Machine Learning seem to be able to help health professionals in “ruling out” when conducting medical screening
John Brandt Brodersen is a general practitioner with over thirty years of experience in clinical practice. Dr Brodersen has a PhD in public health and psychometrics and works as a professor in the area of prevention, medical screening, overdiagnosis, overmedicalization, evidence-based medicine and multi-morbidity at the Centre of Research and Education in General Practice, Department of Public Health, University of Copenhagen and at the Primary Health Care Research Unit, Region Zealand. He is also a visiting professor at the Research Unit for General Practice, UiT The Arctic University of Norway.
Professor Brodersen has been awarded several scholarships and in 2015 was awarded the Nordic research prize "Magda and Svend Aages Frederiechs mindelegat". He is the president of EUROPREV, the European Network for Prevention and Health Promotion in Family Medicine and General Practice, WONCA Europe’s network for prevention. Brodersen is also a member of the board and scientific committee of the international society Preventing Overdiagnosis and he is a member of the advisory board for Wiser Healthcare (https://www.wiserhealthcare.org.au/) and the CHRC, the Comprehensive Health Research Centre in Lisbon (https://www.chrc.pt/en).
We wanted to sit down with John to know more about EUROPREV’s activities and his thoughts about how AI can impact diagnosis and treatment in the future
1.- When did you become interested in Prevention and Health Promotion and why? I have been interested in prevention since I was matriculated at the medical faculty at the University of Copenhagen in 1984. During my internship, I had ½-year in general practice and I realized that prevention could also be very harmful. Therefore, I started to read about evidence-based prevention. This also led to my thoughts and ideas around my PhD, which was a project about the psychosocial consequences of false-positive screening mammography.
During my PhD, which I conducted as a 60% PhD student and 40% GP, I learned about the four types of prevention in general practice and I became especially interested in quaternary prevention, which for me is a pragmatic, ethically sound, patient-centred, evidence-based way of practicing general medicine, minimizing harm and maximizing benefits.
2.- How would you introduce the European Network on Prevention and Health Promotion in Family Medicine and General Practice (EUROPREV) to our readers? The delegates of EUROPREV are trainees and GPs, who have a great interest in prevention related to our patients’ and the European populations’ health. We all support that prevention should be evidence-based, where the benefits should outweigh the harms. We want to talk against the discourses that all prevention is good. Some prevention is low-value care or harmful care, e.g. general health checks, individual so-called lifestyle consultation with apparently healthy citizens, PSA screening, low-dose CT screening for lung cancer, ovarian cancer screening with CA-125 and ultrasound.
3.- What are EUROPREV’s aims for the next years? Our goals for the next year are: (1) to get our delegates to become more active in our network; (2) to run some webinars; (3) to meet physically twice and online 2-4 times during the next year; (4) to update our bylaws and to start the process of legalizing EUROPREV as a body.
4.- “Less is more” seems counterintuitive. You produced EUROPREV’s statement “In cancer screening, often less is MORE” about European Commission announcement in 2022 of a new EU approach on cancer detection – “screening more and screening better”. What can we do about it? To most people, including physicians and some GPs, it is counterintuitive that prevention can do more harm than good. However, we have robust evidence of high quality that conducting general health checks among apparently healthy people does no good, only harm. I would like to quote Raffle & Gray, who wrote in the 1st edition of their book “Screening. Evidence and Practice” from 2007: “All screening programs do harm. Some do good as well and, of these, some do more good than harm at reasonable cost.” This is also why JAMA has started a special issue in their journal called “Less is more” and BMJ “Too Much Medicine”.
Some of the most serious harm related to medical screening is false positives and overdiagnosis, which I have conducted research for more than 20 years. This is also why I am a part of the society “Preventing overdiagnosis” which had its first conference in 2013 in the US.
Going back to your question and taking all the facts above into account: the reason why EUROPREV wrote “In cancer screening, often less is MORE” is that we have an evidence-based approach to medical screening. Moreover, the best available evidence about the benefits and harms of medical screening tells us that most screening programs are either low-value care or harmful care and only in very few cancer screening programs, for a very narrow target group, the benefits might outweigh the harms.
5.- What are the main challenges for disease prevention and health promotion in general practice/family medicine in Europe? The greatest challenge in disease prevention and health promotion in general practice is that those who are in greatest need (people living at the deep end of our societies) are not able to follow the advice their GP gives them (e.g. due to lack of resources financially, socially, mentally and existentially) and those who do not need disease prevention and health promotion – the worried well – are those who fill up our waiting rooms and want more testing.
Moreover, in primary and secondary prevention best available evidence shows us that only structural prevention is beneficial.
Therefore, besides vaccination programs and delivering services for evidence-based mass screening programs (e.g. cervical cancer screening among non-HPV-vaccinated women) GPs should not conduct individualized primary and secondary prevention.
However, GPs should continue conducting patient-centred, evidence-based tertiary prevention – and, of course, quaternary prevention.
6.- European Forum on Prevention and Primary Care 2024 took place 25th-27th April in Edirne, Turkey, with the theme “Less is more”. It was organized in collaboration with EYFDM and TAHEK 2024. What can you tell us about it? We have produced a devoted newsletter about the conference: Click here for more info
7.- What will be EUROPREV’s contributions to next WONCA EUROPE 24 Conference (theme “The changing nature of family medicine. Cultivating the future”)? EUROPREV will contribute with a workshop in Dublin titled: “Soon we will all be patients. Different Scientific Perspectives on Overdiagnosis”. I hope to see many of you at our workshop.
8.- EUROPREV ran five e-learning webinars in 2023. What are the main lessons learned? Many GPs in Europe are concerned about preventive initiatives that deliver low-value care and harmful care, increase social inequity, and are unsustainable for our healthcare systems, our societies and the climate.
9.- What are the relations of EUROPREV with the rest of the WONCA Europe networks and Special Interest Groups (SIG)? We have great relationships with the other networks and we invite the other networks to our yearly forum. We are also invited to the other networks’ forums and we do our best to send at least one of our delegates to these meetings. We also communicate across the networks about common issues and problems, e.g. bylaws and being a legalized body.
10.- What do you think will be the impact of Artificial Intelligence (AI) and Machine learning on Prevention and Health Promotion in Family Medicine and General Practice in the next 10 years? Together with associate professor Alexandra Jønsson, who is a medical anthropologist, I have written the first-ever textbook on Overdiagnosis for university students and the medical and social sciences faculties. There are 8 chapters in the book and one chapter is about Big Data, Personalized Medicine and AIand Machine Learning.
There is spare evidence of how AI and Machine Learning will affect prevention and health promotion in general medicine; however, the evidence shows that it will surely result in a lot of overdiagnosis if we use AI and Machine Learning in individualized primary prevention and if we use AI and Machine Learning to “rule in” (finding more abnormalities) when we conduct screening.
In contrast, AI and Machine Learning seem to be able to help health professionals in “ruling out” when conducting medical screening. My guess would also be that AI and Machine Learning could be a helpful tool in the future for GPs when they should do tertiary prevention.
11.- How do you think Prevention and Health Promotion in Family Medicine and General Practice will be ten years from now? First, I hope that GPs in Europe will conduct more evidence-based prevention and health promotion and thereby follow our core values. This will lead to less medicalization of our apparently healthy patients.
Second, I also hope that our politicians and health authorities will realize that they should implement primary prevention only at a societal level, and talk against individualized primary prevention.
My third, and probably unrealistic hope, is that our screening programs will be monitored for their qualities: how much they benefit and how much they harm. If the monitoring shows that the benefits might not be as great as expected and the harms might be greater than expected, then I hope that our health authorities will have the courage to start de-intensifying such screening programs (e.g. via a stepped-wedge design) to ensure that benefits outweigh the harms with less screening. If for example primary prevention is implemented for something that is screened for (a case could be HPV vaccination and cervical cancer screening) or the treatment for a condition becomes better (for example surgery and chemotherapy for breast cancer) then screening is less beneficial per definition.
Therefore, such improvements should lead to monitoring of screening programs and de-intensifying the screening – or maybe even de-implementing the screening programs.
12..- World Family Doctor Day (WFDD) 2024 with the logo “Healthy Planet, Healthy People” has just been held. What do you think about it? What were EUROPREV’s contributions? I think that we need to rethink our position as healthcare professionals when it comes to “Healthy Planet, Healthy People”. Besides childhood vaccination programs, Medicine as a profession, is not contributing to improving people’s health. Actually, our healthcare systems contribute quite much to our national carbon emissions by around 6-7%. At the same time, 30% of what we are doing clinically is low-value care and 10% is harmful care. Only 60% is good clinical practice. So, anno 2024 GPs are not a part of the solution of how to get a healthy planet and healthy people. We are a part of the problem by overusing, overtesting, overtreating and overdiagnosing people.
Therefore, EUROPREV’s contribution should be to plead for evidence-based general practice by minimizing, mitigating and avoiding low-value and harmful care, by working patient-centered, and by pleading for continuity. Some of us call this quaternary prevention.
13.- Which book are you reading now, and do you recommend it? I am reading Hartmunt Rosa’s book Alienation and Acceleration. I can strongly recommend his book, where HR gives us sociological and philosophical theories, reasons, causes and explanations as to why prevention medicine has gone astray.
Thank you very much for your time John.