Today I want to talk about what is undoubtedly one of the most important medical books I’ve ever read. However, there is no mention of gut flora, or endotoxins or increased intestinal permeability in this work. Nor is there any discussion about hormones, arterial health or the benefits of exercise. You will not learn how to correct digestive upsets by reading it. And you will not learn a thing about what diet to consume for optimal health.
So you may be asking yourself why I consider it such an important book? Because it is meant to prevent you and your loved ones from becoming unwitting victims of the medical system.
I imagine what’s written in this book is more applicable to the U.S. healthcare system. As far as I’m concerned, the profit motive and health care are as compatible, from the perspective of the patient, as oil and water. Nevertheless, I suspect some of the criticisms are equally applicable to state-run health care systems outside of the United States.
In Overdiagnosed: Making People Sick in the Pursuit of Health, Doctors Welch, Schwartz and Woloshin make the argument that diagnostic testing, while certainly important for the ill, can be downright hazardous to the health of what I like to refer to as the worried well. These are folks who have nothing obviously wrong with them, but for a variety of reasons have been convinced that early screening, whether for cancer or cholesterol or some other disorder, is always the right thing to do:
“As I’ve noted, the conventional wisdom is that more diagnosis—particularly, more early diagnosis—means better medical care. The logic goes something like this: more diagnosis means more treatment, and more treatment means better health. This may be true for some. But there is another side to the story. More diagnosis may make healthy people feel more vulnerable—and, ironically, less healthy. In other words, excessive diagnosis can literally make you feel sick. And more diagnosis leads to excessive treatment—treatment for problems that either aren’t that bothersome or aren’t bothersome at all. Excessive treatment, of course, can really hurt you. Excessive diagnosis may lead to treatment that is worse than the disease. More specifically, this book is about overdiagnosis. While the term sounds like it means simply “excessive diagnosis,” it actually also has a more precise meaning. Overdiagnosis occurs when individuals are diagnosed with conditions that will never cause symptoms or death.”
Welch, H. Gilbert; Lisa Schwartz; Steve Woloshin (2011-01-18). Overdiagnosed Beacon Press. Kindle Edition.
These physicians also make clear what this book is not about:
“This book is not about what you should do when you are sick. It is not for the few who are severely ill (those for whom medical care offers a lot), but for the many who are (or used to be) basically well—or those who have one illness and are at risk of being told they have others. Nor is this book an apology for sloppy diagnosis in the sick. Diagnosis is always important when people are suffering, and it’s important that it be done well. None of my comments should be construed as suggesting you are better off not being diagnosed when you are sick. Finally, this book is not a condemnation of all of American medicine, nor a call for alternative medicine. I’m conventionally trained in Western medicine, and I believe doctors do a lot of good. If you are sick, you should see one.”
Many of the screening tests that come under scrutiny within the pages of this book are familiar to most of you:
- tests to measure cholesterol, blood pressure and blood sugar
- routine screening for cancers of the prostate, breast and thyroid
- testing for osteoporosis
- X-rays, MRIs, CT scans and PET scans
- sonograms during pregnancy
- EKG screening for heart disease
- genetic testing
Abnormalities in any of these tests can set in motion a cascade of medical events that can often leave the patient worse off. One such example is this one:
“One of my neighbors has a good friend who lives outside of New York City. Lara regularly comes north to Vermont to escape the city, so I’ve gotten to know her over the years. She’s a healthy sixty-five-year-old woman who nonetheless has managed to get entangled in quite a cascade of diagnosis and intervention. It started when Lara was screened for osteoporosis almost a decade ago. Her bone mineral density test showed that her T score was −1.8. Even though no one calls that osteoporosis (yet), her primary care doctor told her that she was at risk for fracture even though she had none of the aforementioned risk factors. (In this sense, we are all at risk.) She was also told that treatment was both easy and effective.
She told me that her reaction at the time was Why not? So she was started on hormone replacement therapy, which has been shown to increase bone density and reduce the chance of fracture. She tolerated the medicine well. Then along came the major randomized trials of hormone replacement therapy that confirmed its beneficial effects on bone strength but also demonstrated harmful effects—an increased risk of heart attacks and stroke, and an increased risk of breast cancer. Her doctor suggested she not take the medicine anymore and instead try a different medication for osteoporosis.
Lara was started on one of the bisphosphonates and did all right—for a while. Then she developed terrible pain when swallowing. She was referred to a gastroenterologist, who performed an endoscopy (a procedure in which a fiber-optic scope is passed through the mouth into the stomach) and found that she had severe inflammation and ulcers in her esophagus—a known side effect of bisphosphonates. She was switched to another medicine. The esophagitis healed, but a painful rash appeared all over her body. So she was referred to a dermatologist, who suspected that the rash was due to the medication. The medication was stopped, and the rash went away.
Lara had become a medical challenge because doctors couldn’t figure out how to treat her. She was referred to an endocrinologist. Because osteoporosis is considered an endocrine disorder, endocrinologists are thought to be the experts in its treatment; just the people to send the osteoporosis patient who is a medical challenge.
Lest you forget, Lara didn’t even have osteoporosis. At worst, she had osteopenia (you can think of that as preosteoporosis). And she didn’t have any of the risk factors that would make a fracture more likely. Ideally the specialist would rethink the most fundamental question: is this a condition that warrants treatment? Based on Lara’s T score and the absence of other fracture risk factors, her chances of having a fracture were low; consequently, the benefit of treatment would be small at best.
But the endocrinologist didn’t raise this point; he was dealing with a medical challenge. So he conducted a thorough evaluation of all her glands and hormones. The evaluation included a careful physical exam of the thyroid gland, during which the endocrinologist thought he felt a lump. Lara was referred to a radiologist, who did an ultrasound exam of the thyroid and who found three lumps (the largest of which was about an inch in diameter). She had needles stuck in all of them and some fluid removed from each. Some of the cells in the fluid looked concerning under the microscope. The pathologist worried that they might be cancer, but the only way to know for sure was to remove her thyroid. So she was referred to a surgeon.
Imagine that. You feel fine, but someone suggests a test to see how strong your bones are. The test shows your density is just a little below average for your age. But you are considered at risk for fracture and encouraged to take action. Three medications and three specialists later, you are told you might have thyroid cancer. Quite a cascade. At least there’s a happy ending in this case. A surgeon—I would say a prudent one—put a stop to it. He knew that virtually all adults have some evidence of thyroid cancer. Most important, Lara is fine—I just saw her kayaking on the Connecticut River—but now she’s a little more hesitant to look for things to be wrong.”
Lara was lucky in that she saw a surgeon who was not motivated by making a quick buck, and who put a stop to events that could have left her dependent on thyroid medication for the rest of her life. Unfortunately, many others are not so lucky.
This book has really opened my eyes, and has made me a better and more cautious consumer of medical services. I’ll be forever grateful to these doctors for alerting me to the downsides of screening.
Overdiagnosing is not just a problem in conventional medicine, however. There are many tests of dubious quality administered to unsuspecting people seeing alternative-care practitioners. I wrote about one such instance in this post. While some of the harm may be limited to a drained bank account, the worry, anxiety and treatments provoked by some of these tests can be every bit as damaging.
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