Overdiagnosed

by WELCH, H. GILBERTSCHWARTZ, LISA

• ISBN13: 9780807022009
• ISBN10: 0807022004
• Format: Hardcover
• Copyright: 2011-01-18
• Publisher: Beacon Press

Summary

From a nationally recognized expert, an exposeacute; of the worst excesses of our zeal for medical testing Diagnoses of every condition, from high cholesterol and high blood pressure to osteoporosis, diabetes, and even cancer, have skyrocketed over the last few decades. Yet Americans are living longer than ever. While the medical establishment credits aggressive early disease detection as the cause of improved public heath, it is in fact the reason so many of us are told we are sick. Going against the conventional wisdom that more screening is the best preventive medicine, Dr. H. Gilbert Welch builds a compelling counterargument that what we need is fewer, not more, scans and tests. Drawing on twenty-five years of medical practice and research on the effects of screening, Welch explains how the cutoffs for "abnormal" test results have been drastically lowered while at the same time technological advances have enabled doctors to detect more and more "abnormalities," many of which will pose no health complications. Now, with genetic and prenatal screening common practice, patients are increasingly being diagnosed not only with disease but with "pre-disease." Examining the social, medical, and economic ramifications of a health care system that unnecessarily diagnoses and treats patients, Welch makes a reasoned call for change that would save us from countless unneeded surgeries, debilitating anxiety, and exorbitant costs.

Table of Contents

Introduction: Our Enthusiasm for Diagnosis	p. ix
Genesis: People Become Patients with High Blood Pressure	p. 1
We Change the Rules: How Numbers Get Changed to Give You Diabetes, High Cholesterol, and Osteoporosis	p. 15
We Are Able to See More: How Scans Give You Gallstones, Damaged Knee Cartilage, Bulging Discs, Abdominal Aortic Aneurysms, and Blood Clots	p. 32
We Look Harder for Prostate Cancer: How Screening Made It Clear That Overdiagnosis Exists in Cancer	p. 45
We Look Harder for Other Cancers	p. 61
We Look Harder for Breast Cancer	p. 73
We Stumble onto Incidentalomas That Might Be Cancer	p. 90
We Look Harder for Everything Else: How Screening Gives You (and Your Baby) Another Set of Problems	p. 102
We Confuse DNA with Disease: How Genetic Testing Will Give You Almost Anything	p. 116
Get the Facts	p. 136
Get the System	p. 151
Get the Big Picture	p. 167
Conclusion: Pursuing Health with Less Diagnosis	p. 180
Acknowledgments	p. 192
Notes	p. 194
Index	p. 218
Table of Contents provided by Ingram. All Rights Reserved.

Excerpts

My first car was a ’65 Ford Fairlane wagon. It was a fairly simple—albeit
large—vehicle. I could even do some of the work on it myself. There was a lot
of room under the hood and few electronics. The only engine sensors were a
temperature gauge and an oil-pressure gauge.

Things are very different with my ’99 Volvo. There’s no extra room under
the hood—and there are lots of electronics. And then there are all those little
warning lights sensing so many different aspects of my car’s function that
they have to be connected to an internal computer to determine what’s wrong.
Cars have undoubtedly improved over my lifetime. They are safer, more
comfortable, and more reliable. The engineering is better. But I’m not sure
these improvements have much to do with all those little warning lights.
Check-engine lights—red flags that indicate something may be wrong
with the vehicle—are getting pretty sophisticated. These sensors can identify
abnormalities long before the vehicle’s performance is affected. They are
making early diagnoses.

Maybe your check-engine lights have been very useful. Maybe one of
them led you to do something important (like add oil) that prevented a much
bigger problem later on.

Or maybe you have had the opposite experience.

Check-engine lights can also create problems. Sometimes they are false
alarms (whenever I drive over a big bump, one goes off warning me that
something’s wrong with my coolant system). Often the lights are in response
to a real abnormality, but not one that is especially important (my favorite is
the sensor that lights up when it recognizes that another sensor is not sensing).
Recently, my mechanic confided to me that many of the lights should
probably be ignored.

Maybe you have decided to ignore these sensors yourself. Or maybe
you’ve taken your car in for service and the mechanic has simply reset them
and told you to wait and see if they come on again.

Or maybe you have had the unfortunate experience of paying for an
unnecessary repair, or a series of unnecessary repairs. And maybe you have
been one of the unfortunate few whose cars were worse off for the efforts.

If so, you already have some feel for the problem of overdiagnosis.

I don’t know what the net effect of all these lights has been. Maybe they
have done more good than harm. Maybe they have done more harm than
good. But I do know there’s little doubt about their effect on the automotive
repair business: they have led to a lot of extra visits to the shop.

And I know that if we doctors look at you hard enough, chances are we’ll
find out that one of your check-engine lights is on.

A routine checkup

I probably have a few check-engine lights on myself. I’m a male in my midfifties.
I have not seen a doctor for a routine checkup since I was a child. I’m
not bragging, and I’m not suggesting that this is a path others should follow.
But because I have been blessed with excellent health, it’s kind of hard to
argue that I have missed out on some indispensable service.

Of course, as a doctor, I see doctors every day. Many of them are my
friends (or at least they were before they learned about this book). And I can
imagine some of the diagnoses I could accumulate if I were a patient in any
of their clinics (or in my own, for that matter):

• From time to time my blood pressure runs a little high. This is particularly
true when I measure it at work (where blood pressure machines are
readily available).
Diagnosis: borderline hypertension

• I’m six foot four and weigh 205 pounds; my body mass index (BMI) is 25.
(A “normal” BMI ranges from 20 to 24.9.)
Diagnosis: overweight

• Occasionally, I’ll get an intense burning sensation in my midchest after
eating or drinking. (Apple juice and apple cider are particularly problematic
for me.)
Diagnosis: gastroesophageal reflux disease

• I often wake up once a night and need to go to the bathroom.
Diagnosis: benign prostatic hyperplasia

• I wake up in the morning with stiff joints and it takes me a while to loosen
up.
Diagnosis: degenerative joint disease

• My hands get cold. Really cold. It’s a big problem when I’m skiing or
snowshoeing, but it also happens in the office (just ask my patients). Coffee
makes it worse; alcohol makes it better.
Diagnosis: Raynaud’s disease

• I have to make lists to remember things I need to do. I often forget
people’s names—particularly my students’. I have to write down all my
PINs and passwords (if anyone needs them, they are on my computer).
Diagnosis: early cognitive impairment

• In my house, mugs belong on one shelf, glasses on another. My wife
doesn’t understand this, so I have to repair the situation whenever she
unloads the dishwasher. (My daughter doesn’t empty the dishwasher, but
that’s a different topic.) I have separate containers for my work socks,
running socks, and winter socks, all of which must be paired before they
are put away. (There are considerably more examples like this that you
don’t want to know about.)
Diagnosis: obsessive-compulsive disorder

Okay. I admit I’ve taken a little literary license here. I don’t think anyone
would have given me the psychiatric diagnoses (at least, not anyone outside
of my immediate family). But the first few diagnoses are possible to make
based solely on a careful interview and some simple measurements (for example,
height, weight, and blood pressure).