Protect yourself from overtreatment
Posted by medconsumers on March 7, 2011
Overdiagnosed—Making People Sick in the Pursuit of Health is a new book by three physicians whose work I admire. All are practising physicians, researchers, authors, and professors at the Dartmouth Institute for Health Policy and Clinical Practice. Here is my recent interview with the lead author, H. Gilbert Welch, MD.
Maryann Napoli (MN): You say that overdiagnosis is the biggest problem posed by modern medicine. “It has led millions of people to become patients unnecessarily, to be made anxious about their health, to be treated needlessly, and to bear the inconvenience and financial burdens associated with overdiagnosis. It has added staggering costs to our already overburdened health care system. And all of the forces that helped create and exacerbate the problem — financial gain, true belief, legal concerns, media messages, and self-reinforcing cycles — are powerful obstacles to fixing it.” What exactly is overdiagnosis?
H. Gilbert Welch (HGW): Overdiagnosis occurs when we doctors make diagnoses in individuals who are not destined to ever develop symptoms or die from the condition being diagnosed. In general, overdiagnosis is a side effect of our relentless desire to try to find early disease and that happens through annual check-ups and screenings.
MN: How can people reduce their chances of being overdiagnosed?
HGW: People are sensitized to think about the side effects of treatment, but they are less sensitized to think about the side effects of looking for things to be wrong—testing and screening. Diagnosis can start a train of events that can be very difficult to stop. My co-authors, Lisa M. Schwartz and Steven Woloshin, and I write about the need for those who are well to develop a bit of healthy skepticism about the process of looking for things to be wrong. We are encouraging people to ask themselves whether they want to be part of this testing process that could start a cascade of more tests and interventions…and anxiety. They may decide that they want to – and that’s fine. Our interest is not to say, “you should or you shouldn’t [have a test if you have no symptoms]”. We just want you to know that there are two sides to the story – harms as well as benefits.
MN: Your book provides quite a service by explaining the benefits and harms of taking drugs for each level of high blood pressure, ranging from very mild to severe.
HGW: I start the book with hypertension because it was the first place that we physicians began to prescribe drugs for people without symptoms – in other words, it was the first place overdiagnosis was possible. We’ve studied hypertension so much that we know that the benefit is a function of how high your blood pressure is. If you have really high blood pressure, the benefit is enormous. Treating these patients is one of the most important things we do.
MN: What about the many people who have only mild or very mild high blood pressure and they are strongly urged by their doctors to take drugs for it?
HGW: As we move to treat lower and lower blood pressures, the benefit of treatment falls. People should know how high their blood pressure is and should ask about size of the benefit because all our treatments have some harms. The harms start with the hassle factors like arranging followup appointments, getting your prescription, dealing with insurance companies, which all add complexities to our lives. Then there are the more serious harms of drug side effects that are more rare. Increasingly, treatment is being encouraged for low-risk persons – people with minimal blood pressure elevation (or minimal blood sugar or cholesterol elevations). In these situations we’re looking at helping about of one out of a hundred. In this book, we’re raising the question: What happens to the other 99? And let’s be clear — the treatment is always the patient’s choice.
MN: There are studies, dating back to the 1970s, showing that the annual physical is not necessary, but the public largely remains keen on it.
HGW: If the annual checkup means complete head-to-toe physical and series of tests, etc., it is not a sensible or an important intervention. If, however, the annual checkup is a “check-in”, then it makes sense. To get a sense of what health risks patient may face, we explore your lifestyle and your family history. We talk about health promotion— eat your fruits and veggies, exercise, don’t smoke, develop meaningful relationships, etc. Most importantly, we learn what’s going on in your life and what matters to you. It should be an exploration, not some concerted effort to look for things that are wrong. You may choose to pursue some forms of early detection, but you should know these efforts are more problematic. The truth is we all have abnormalities.
MN: You write about the expanding definitions of diseases like osteoporosis, diabetes 2, hypertension that overnight make millions of healthy people into patients in need of long-term drug treatment. You point out that the sellers create the demand and exploit buyers to make more profit.
HGW: The pharmaceutical industry is the big whipping boy and it deserves to be. But there are other powerful forces, namely hospitals looking to expand their markets. Hospitals, for example, understand that free cancer screening is a great strategy for recruiting new patients. That was addressed nicely in your 2003 interview with Dr. Otis Brawley then the head of Emory University’s Cancer Center, whose PR people were encouraging prostate cancer screening as a long-term money-maker for the hospital (click here). Lawyers are also part of the story. We doctors are sued for underdiagnosis [i.e., failure to diagnose], but never for overdiagnosis. And then there’s the media, trained to provide powerful anecdotes – typically cancer “survivors” who say they owe their lives to the cancer screening test. These are among the most misleading anecdotes in medicine. I hate to say this, but the typical breast or prostate cancer survivor detected by screening is more likely to be overdiagnosed than truly helped by screening.
MN: Yes, one-third of all mammography-detected breast cancers would never become life-threatening had they gone undiscovered and untreated. click here And Otis Brawly, MD, now the chief medical officer of the American Cancer Society, has said that the PSA screening test for prostate cancer is 50 times more likely to ruin a man’s life (unnecessary cancer treatment) than save a man’s life. click here
HGW: There an incredible paradox here. The more sensitive a test becomes, the more cancers we see, and the more overdiagnosis. That translates into more survivors stories featured in the media, the more likely people actually know a survivor and the more popular the test becomes.
MN: I gather you’re down on the current efforts to hold physicians to performance measures.
HGW: It makes sense to find out how well things are going in medicine. Unfortunately, some of our performance measures are brain dead. They are often based on what we do to well patients—for example, all women should have mammogram, regardless of whether we are telling them both sides of the story—regardless of whether we are coercing them into having this test. The incentive for doctors is to get good grades. To me, this is ridiculous. We should not be measured on persuasion. These decisions belong to individuals.
Maryann Napoli, Center for Medical Consumers(c)