Neil Hopcroft

A digital misfit

Book review: Overdiagnosed

[Listened as audiobook]

https://www.penguinrandomhouse.com/books/205067/overdiagnosed-by-h-gilbert-welch

This is a book about overdiagnosis of medical conditions, it digs in to the problems of screening and some implications of discovery of “incidental-oma”s, growths seen on a scan but unrelated to the reason for the scan, and other incidental findings.

This book has put into perspective some of the things that were worrying me about screening – I knew screening was often detrimental, but I hadn’t understood quite how bad it is. There are some situations where screening is worthwhile, and likewise where medical control of proxies is worthwhile, breast cancer screening and high blood pressure being good examples. Many other screening exercises lead to anxiety and risk from intervention without improving overall outcomes.

There was also some discussion of the extension and redefinition of disease to include more people in the condition – if a condition is measured, adjusting the cutoff point for diagnosis so mild versions of the disease are included. When we do this, more people undergo more invasive diagnosis and treatment, even when the condition is not interfering in their lives.

There are also some psychological and cultural aspects to the perpetuation of screening, where people believe that they have been saved by a doctor who found something they were totally unaware of and treated it. These people then become advocates for screening, “catch it early”, “it will save your life”.

The thing to look out for is the number needed to treat, if you need to treat three or four people to save one, as is the case with high blood pressure, it is clearly worthy. If you need to treat a thousand to save one, the value is much less clear cut – indeed, if those thousand then go through a procedure or take a medicine which carries risk, as most do, you don’t need to have many side-effects or bad outcomes to cancel out that one saved per thousand.

Another concern considered in the book is about the use and abuse of statistics, looking at things like ten year survival rates from initial diagnosis doesn’t hold any value in those cases where diagnosis is accelerated by screening.

This book is grounded in the American system, where there are more financial incentives to overdiagnose otherwise well people to turn them into patients, especially where the only way to know if you are getting better is to have another scan and have the radiologist tell you it looks better – there is no symptom to be relieved.

I’m not sure how well it translates to the British health system – I would like to think that the NHS is better able to understand, and therefore deal with, the problems of overdiagnosis. The NICE guidelines should incorporate mitigations for the worst overdiagnoses, but I am also sure that there will be significant pressure from the public, and some well meaning but not so well (statistically) educated medical professionals, to perform more screening, more finding things early.

Postscript: While I was writing this review the BBC published an article about How AI can spot diseases that doctors aren’t looking for. This article is an example of the perpetuation of the myths of early diagnosis – the protagonist in the piece was ‘identified’ as having osteoporosis based on machine readings of his bone density, which is claimed human doctors are biased against looking for in middle age men – it is considered more prevalent in old thin white women. The machine was looking at a scan taken for GI related issues. This is a classic example described in the book, with a symptom free vertebra collapse and low measured bone density without any symptoms like frequent fractures. Oddly, it is only at the end of the article that there is a nod toward the harms of this kind of incidental screening, and even then it concentrates more on the harm to the NHS than the people diagnosed.

The only bit of sense in the whole article is from Prof Javaid: “We want to build the evidence to use it across the NHS”. Building this evidence in a reliable way is non-trivial, and probably involves longitudinal studies of thousands and carefully designed RCTs. My expectation would be that there are a few things where the results indicate significant improvement in overall outcomes without undue anxiety or risk, but most screening will show that it either doesn’t improve outcomes, or worse, actually causes harm. But I don’t think we have the data yet to draw robust conclusions. And I doubt there will be much funding for these kinds of studies – pharma and medical tech won’t want to go looking for results that say you should use less of their products.


Along the waterfront

Looking back: I have always found waterfronts magical, especially when they are reflecting city lights in the distance – Stockholm has an abundance of such views.

Stockholm has a lot of waterfront – it is a city made of islands, 24000 of them in the archipelago although the city centre rests on something like 10 main islands at the junction between the Baltic Sea and Lake Mälaren. It is not surprising, therefore, to find lots of interesting things on the waterfront.

Spirit of the Wild photo exhibition in Nybroplan/Berzelii Park
Data obelisks
Naval band




Runestone in Helenelund

Looking back: this was the first of many runestones I found, it became a bit of a treasure hunt for me to find and photograph them.

There are a number of Rune Stones around the Stockholm area – one thing that A wants to do while she is here is to find some of them. This one I came across by accident and took a picture with the intention of finding someone who knew what it was.

There is a small informational plaque next to the stone, but that only has Swedish description so I was no wiser.

The rune stone
Its location outside Kummelby kyrka on Sollentunavagen


A walk around Helenelund

Looking back: The little roads were more prevalent in this area of northern Stockholm than elsewhere in the city. These roads are widely used by cyclists and walkers alike, and, at the right time of year, skiers.

If instead of walking toward the Galleria from my office you cross the E4 and railway line you find yourself in Helenelund, a residential district on the edge of Sollentuna, itself a suburb of Stockholm. Trains run from Helenelund to Central Station.

Pendeltag or J-Train station at Helenelund
The shopping centre by the station
Some tags on a lamppost, I’ve no idea what they mean
Roadsigns at the junction of residential roads
Cycle/Pedestrian paths – there are lots of these ‘little roads’, making two networks separating vehicle and pedestrian traffic




Kista Landing

Looking back: we spent a lot of time in Kista, being where I worked and where we lived for a good chunk of time we were in Sweden.

I arrived in Kista a couple of months back, I started a job on Torshamnsgatan in the tech district of Stockholm. Now I have some catching up to do to tell you about what I’ve found here.

Kista (pronounced ‘Shiister’) is a relatively new district, built over the last 40 years or so, home to much of the technology research and development in Stockholm. You might be forgiven for thinking the whole place was owned by Ericsson, but there are many other companies here.

One of the Ericsson offices
Boulevards in the area
Kista Science Tower


Sollentuna bound

Looking back: we were later to become very familiar with Sollentuna, living there for our last months in Sweden – Sollentuna Centrum would become our local shopping centre after its refurbishment.

We walked over the bridge from our flat in Akalla, heading toward Sollentuna Centrum. There’s an industrial/commercial area on the way, we passed a number of car dealerships and tech offices, Sun, Grundig, LG & Microsoft.

Beyond these there’s the main junction with the E4, the main road north from Stockholm, we found the border between Stockholms Kommun and Sollentuna Kommun.

Entering Sollentuna itself we encountered what appeared as if it should be a shopping centre, but without any shops in – there was a row of blocks of flats with shops underneath them, but it was not like the centre we were expecting to find.

We went around the block where we found the station – and decided it might be worth a look on the other side on the offchance there might be more of the centre there. We discovered a building marked ‘Sollentuna Centrum’ so that seemed like a good place to look for lunch. No joy. Its just a small building containing a few shops. Just across the way theres another building that looks rather like a car park, which, it turns out, contains a more significant shopping experience. Unfortunately we were there around 4:30 so all of the food shops were closing so we had to opt for a kebab at the one place that still looked open.


Book review: The Last London by Iain Sinclair

The Last London [Read aloud to Adelle]

I got this book because we were reading London Orbital, Sinclairs book about a walk around London in the acoustic footprint of the M25 and didn’t want it to finish. More about that book later. This was a tricky read, with complex sentences that didn’t come out in one breathe. His writing style is intense, with many observations on people and things he encountered on his walks.

The majority of the book revolves around his locality in Haggerstone, spiralling outwards to eventually end up recreating a force march to the battle of Hastings with a parade of misfits lead by an unattached bride. This is a political discourse on the turmoil of Brexit, both before and after, an observation of the schisms in the mentality of the country.

I knew a surprising number of the places through which the recorded walks passed, and was offered a view different from those I have seen during my own ambling, with a peak into the ancient or, more often recent history, of places.

One such place I didn’t know about was Mortimer Road, home of The Mole Man of Hackney, a mere couple of miles from my first flat in London, where an eccentric Irishman burrowed an extensive network of tunnels. Karen Russo said the Mole Man proved to be extraordinarily difficult to work with, and we are left with only a few pictures of the contents of his tunnelling.

London Orbital was where it started, this was a book I read not long after it came out at the beginning of the century. It captured a time in my life when the orbital was central, when discovery of things off the tarmac was a view into a world that was not there, that did not exist because you join, you drive, find your junction and leave. There is something in all those miles in between. And, for the most part, it is asylums or plague hospitals, places to put the unseen of Victorian society so they remain unseen. And they remain unseen, for different reasons now.

I read this book to Adelle too, and was reminded of the hopeful future that pervaded my life at the time of my own escape from the gravitational capture of the capital. It is a book of its time, a time now passed, making it a history of sorts, I am pleased to note that there is a 20 year celebration on film.

Wanderlust makes me consider other walks that could yield similar works, but my control of the language falls far short of that in these books. The A14 was an obvious candidate, at one point, now there is more appeal to the liminal nature of the north Norfolk coastal path.


Three score years, less six

Stirred to action by unnerving changes to Facebook acceptable speech policy, something I have been meaning to do for a while is to take up blogging again. This is something that happens from time to time, and something which I miss from the old Livejournal days – I don’t kid myself I can generate the kind of community we had in those days, nor am I going to kick myself if it doesn’t last long this time around either.

This will be a two-pronged approach, firstly to start writing here again, secondly to link to posts made here from platforms where ‘my people’ are found, be that Facebook or Bluesky or other places as and when they are invented. For what it is worth I am @neilhopcroft.com on Bluesky, and @neilhopcroft on mastodon.social, follow me, or not.

The content I aim to post here will cover a few topics, not least of which is some attempt at recovery of my mental health from its current ragged state. I will also touch on technology, politics, economics, rhetoric, diesel traction, book reviews and various other themes, as I see fit.

My old blog from our travels to Stockholm will also see a refresh and repost here, remastering, if it were a record, presented in all its original naïve glory but with bigger brighter pictures, improved grammar and a search button that works.