“Soon we will all be patients”
During his GP training research project, struck by the emotional impact on patients of having a false positive test result, he followed a career exploring evidence, healthcare communication, and overdiagnosis.
John Brandt Brodersen is a General Practitioner and Professor, at the Center for Research & Education in General Medicine, University of Copenhagen and in Region Zealand. He is also a visiting professor at UiT, the Arctic University of Norway in Tromsø. His research and teaching is focused on evidence-based medicine, prevention and risk, with a particular focus on over-diagnosis and psychosocial consequences of false-positive responses in medical screening.
He has published widely in Danish, Nordic and international scientific journals
You can find the video on YouTube or the Podcast on Spotify
Alexandra Brandt Ryborg Jønsson and John Brandt Brodersen with their book ‘Snart er vi alle patients’ ‘Soon we will all be patients’
Lets start at the beginning and your introduction to medicine…
John Brandt Brodersen. At gymnasium, which is school in Denmark when you are between 17 and 19 or 18 and 20 years old, I was really good in maths and physics and all my teachers thought that I should be an engineer. I always loved to talk to people, connect with people, and building relationships. I signed up for the engineering school in Copenhagen but, after working one or two months during my summer holiday, I regretted it. So I gave up the idea. I was looking around and talking to a lot of people and then, one day one of my good friends, she said, ‘John, you have to do something that combines maths and psychology. So. do medicine.’
When I began medical school at the University of Copenhagen, I didn’t really fit in with the other students because most of them were children or grandchildren of other physicians or doctors. I have no academics in my family so it was really difficult for me. After a year I started doing some shifts as a nurse assistant and I just loved being with the patients. It took me eight and a half years to do the six years, because I did a lot of traveling and had sabbaticals and a relaxed time. I finished medical school and was uncertain about what to do because I loved most of the themes that were presented to us.
I started working at the hospital and I thought, this is not human. This is so disease oriented but during my internship I had half a year of general practice and I fell in love with general practice. After trying pediatrics and internal medicine, I decided to train as a GP. During that GP training, which was three and a half years, we had the course in research. We were asked to do a project and I did a project on the consequences of having a false positive result because I had seen some people having false positive results and I was shocked by the emotional reaction to an abnormal test. That was the start, and that ended up with a grant. I had three months preparing the proposal. And then within a year I matriculated as a PhD student and did my PhD on the psychosocial consequences of screening mammography.
During my PhD I started reading some literature around overdiagnosis. I had never heard about overdiagnosis. That was in 2001- 2002. And then I was asked by the weekly Danish journal for physicians to do a kind of review article about the harms of screening mammography. So I looked into the literature around the unintended harms of screening mammography, started reading about overdiagnosis, with the consequence that after my PhD, where I had been doing a lot of research into overdiagnosis, I was now strongly involved in research about overdiagnosis.
“… how should we communicate about overdiagnosis? It’s really an ethical dilemma that we call the tightrope walk…Sometimes we really have as ethical obligation to communicate overdiagnosis. On the other hand, we shouldn’t harm people more than they already harmed. So communicating overdiagnosis is a really fine balance.”
Front covers of the BMJ featuring the work of John and colleagues
DMacA: You talk about unintended events but, as we talk, I can see on the noticeboard behind your head, two front covers of the BMJ, that reflect some of your most dynamic work. Tell us about that work.
JBB: We did a paper around 2010 which ended on the front page of BMJ. It was about what women are told when they’re invited to screening mammography. We looked at all the different invitations from around the world and, as we knew about the best available evidence on benefits and harms, we could then look at it how this was communicated.
It was really biased. It over emphasized all the benefits and under emphasised or ignored the harms. So actually, women in these countries didn’t have the option of a freely evidence based informed choice. I’ve done several studies on information leaflets, but I’ve also gone further and looked at how administrators and authorities that are inviting people, how they frame their invitations. And we found several framing effects. They are all trying to improve or increase the numbers of people participating but they’re actually manipulating the women, because they can’t see through these framing effects. It’s not about nudging because the definition of nudging is that you should be able to see that somebody is doing something with you. For example, if there is a fly pictured on the urinal in the men’s toilet, we can see this fly when we pee, and aim at the fly. So we can easily see when we are nudged. But when women receive those information leaflets, they cannot see that framing effects are used. So, by our definition, they are manipulated.
We tried to create an information leaflet for cervical cancer screening that was evidence based, with all the best available tools, with no framing effects, absolute numbers, and the same denominator for benefits and harms. But the problem was cognitive dissonance. If you have a very strong assumption, or you are told by authorities, or healthcare system, or your GP, that screening is a really fantastic tool to prevent cancer, then you believe that. And when meeting facts that go against your thoughts or your beliefs you can’t perceive it.
We call this the perception gap. And the psychological theory called cognitive dissonance means that, no matter how good the information leaflets or letters might be, it doesn’t help because people can’t perceive it, because it goes against their strong assumptions. So that’s the message that’s shown on one of the BMJ covers
The other BMJ cover one is about communicating- how should we communicate about overdiagnosis? It’s really an ethical dilemma that we call the tightrope walk. Because, when you and I, as a GP, see a male patient that we think is over diagnosed with prostate cancer, this male patient will probably not see any benefit from our conversation if we say- you are overdiagnosed. On the other hand, if someone comes to us who wants a PSA test, they should certainly be told about the harm of overdiagnosis and the risk of overdiagnosis, how many are overdiagnosed, and the balance between benefits and harm? Sometimes we really have as ethical obligation to communicate overdiagnosis. On the other hand, we shouldn’t harm people more than they already harmed. So communicating overdiagnosis is a really fine balance.
DMacA: It’s very interesting because we’ve always been fed the message that, in terms of cancer diagnosis for example, ‘the sooner the better’. But that’s not something you would agree with.
JBB: First of all, cancer is not cancer. Cancer is many different diseases and even the same cancer diagnosis from the same organ is many different diseases. The natural history for breast cancer, or for lung cancer, or for prostate cancer, or whatever, is very heterogeneous. So, we can’t talk about one disease, cancer, we have to talk about it as many different diseases. And for some colorectal cancers, it’s better to diagnose it sooner. However, in prostate cancer, breast cancer, lung cancer, melanoma, thyroid cancer, and kidney cancer, we know that you can also diagnose it too early, that you can find it in a stage where it’s not growing or it’s growing very slowly, and you will die from other causes before you ever get symptoms from this condition. So these idioms, ‘the sooner the better’ or ‘a stitch in time saves nine’ or whatever you say in English, you cannot use these as a one size fits all in early diagnosis. You have to be much more nuanced and balanced. And sometimes early diagnosis is much more harmful than beneficial.
DMacA: Many of us are familiar with your work on cervical cancer and breast cancer. But, not for melanoma where there’s a huge push by our dermatology colleagues for early diagnosis. Tell us a more about that.
JBB: We’re doing quite a bit of research right now on the diagnosis in melanoma and we recently published a scoping review on overdiagnosis and melanoma. We found three studies that estimated the degree of overdiagnosis ranging from 29% to 60%. Paul Glasziou and colleagues looked at data in Australia and estimated that 58% of melanomas were overdiagnosed. So even in a country where you have a lot of white people with a lot of sun, you have a substantial degree of overdiagnosis in melanoma. We also did a Cochrane review on screening for melanoma, and there’s no evidence supporting screening. So, we don’t really have any high quality evidence supporting early diagnosis or screening of melanoma, but we have much robust evidence of different levels of quality showing that is very harmful to look for early diagnosis of melanoma. So, I think we have to rethink the whole issue around early diagnosis and cancer. And we actually just published a paper entitled Rethinking the Logic of Early Diagnosis of Cancer.
This is linear thinking, where earlier is always better, but this is wrong thinking. We have to rethink it. We have to be much more critical. Cancer can be a horrible disease that spreads very quickly and is very deadly. However, it can also be indolent and benign and never become anything of a disease.
DMacA: This is a fascinating topic, you’ve published a lot including a book, and I’ve also seen you described as Mr. Overdiagnosis. Do you get much pushback from colleagues?
JBB: Yes. But, it’s been like this for more than two decades. I’ve done research on overdiagnosis and, in the Danish context, it has been not easy. Two years ago, as you just said, I published a book, the first ever textbook on overdiagnosis. Our target group is university students and medical and social science faculties. It’s written spanning across those two sciences, medical sciences and social sciences. However, it’s been really well received by health authorities, physicians, researchers, journalists, nurses, midwives, physiotherapists, all kinds of health professionals. A really positive reaction, and we’ve had a fantastic positive discussion around overdiagnosis in Denmark. The good news is that we’ve just signed a contract to publish the book in English and we’ve promised to deliver the English manuscript in 2025. Hopefully we will be able to do it before the year is over. I’m both worried and excited about it being published in English. I’m worried that some people will be hostile and aggressive and not accept it, because it’s a scientific book, it’s not a debate. On the other hand, I’m really excited that we can begin to have a proper sober discussion around overdiagnosis which for me, excluding overuse and overtreatment, is the biggest problem we have in medicine. It’s a global problem that we see in all countries and it is destroying people, it’s destroying our health systems, and it’s actually worsening climate change because it increases the carbon footprint.
DMacA: Those are pretty serious and important messages. And we all really appreciate that you’ve asked these difficult questions. But, let me now ask you about something totally different. You are associated with the Arctic University in Tromso, that’s a most unusual place, talk to us a little about that.
JBB: In my younger days I worked as a GP in Norway. The first position I had was as a locum for four months in the beautiful Lofoten Islands, just south of Tromsø. I had a good colleague working as a GP in Tromsø and after my four months, she invited me to come and do the locum for her holidays. So I was there at Christmas, Easter, and Summer. That was during my PhD period. And afterwards, I did a lot of research with my Scandinavian colleagues, including Norwegian colleagues. So I’ve always had a really good contacts with Bergen, Trondheim, and with Tromsø. And then my colleague, May-Lill Johansen who is the leader of the research unit asked me and Alexandra Brandt Ryborg Jønsson if we wanted to be visiting professors because they lacked researchers in general practice and my competencies are in psychometrics and epidemiology and Alex is an anthropologist who is very strong in social science. And we are married. So it was a fantastic for us to have this opportunity to go together to Tromsø where we spend four weeks per year. It also works well, I think, for Tromsø to have us coming with so many years of experience
“So these idioms, ‘the sooner the better’ or ‘a stitch in time saves nine’ or whatever you say in English, you cannot use these as a one size fits all in early diagnosis. You have to be much more nuanced and balanced. And sometimes early diagnosis is much more harmful than beneficial.”
DMacA: We are listening to this very serious academic talking about psychometrics and overdiagnosis and epidemiology and all these really long words, but you have a most unusual and entertaining hobby. As we finish our conversation, tell us a little about your hobby.
JBB: In fact, I have two hobbies. One is that I play soccer, and I really enjoy it, playing with my old friends. And then I play in a brass band, and that’s due to my wife. She forced me to start playing cornet. It was the deal we made when we wrote the book that, when it was finished, I had to start exercising and playing the cornet. So now I play in our local brass band, and actually I participated, just a few months ago, in the world’s biggest brass band competition on Whit Friday, in the South Manchester area of the UK. And it was amazing to see the culture around brass band music in that part of the world. It’s such a big tradition in England, Scotland and Ireland but it’s a very small thing in Denmark.
DMacA: It’s been just fun chatting to you and I’m delighted that we were able reveal that this very serious academic is a brass band cornet player. And we look forward to hearing you play the future. John, thank you very much indeed. It’s been an absolute pleasure.
