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TWO VA DOCTORS CLAIM WHAT'S MAKING US SICK IS
AN EPIDEMIC
OF DIAGNOSES -- "The real problem with the
epidemic of
diagnoses is that it leads to an epidemic of
treatments."
by
Harry Campbell for The New York Times
Story here...
http://www.nytimes.com/
2007/01/02/health/02essa.html?_r=1&oref=slogin
Story below:
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What’s Making Us Sick Is an Epidemic of Diagnoses
By H. GILBERT WELCH, LISA SCHWARTZ and STEVEN WOLOSHIN
For most Americans, the biggest health threat is not avian flu, West
Nile or mad cow disease. It’s our health-care system.
You might think this is because doctors make mistakes (we do make
mistakes). But you can’t be a victim of medical error if you are not in
the system. The larger threat posed by American medicine is that more
and more of us are being drawn into the system not because of an
epidemic of disease, but because of an epidemic of diagnoses.
Americans live longer than ever, yet more of us are told we are sick.
How can this be? One reason is that we devote more resources to medical
care than any other country. Some of this investment is productive,
curing disease and alleviating suffering. But it also leads to more
diagnoses, a trend that has become an epidemic.
This epidemic is a threat to your health. It has two distinct sources.
One is the medicalization of everyday life. Most of us experience
physical or emotional sensations we don’t like, and in the past, this
was considered a part of life. Increasingly, however, such sensations
are considered symptoms of disease. Everyday experiences like insomnia,
sadness, twitchy legs and impaired sex drive now become diagnoses: sleep
disorder, depression, restless leg syndrome and sexual dysfunction.
Perhaps most worrisome is the medicalization of childhood. If children
cough after exercising, they have asthma; if they have trouble reading,
they are dyslexic; if they are unhappy, they are depressed; and if they
alternate between unhappiness and liveliness, they have bipolar
disorder. While these diagnoses may benefit the few with severe
symptoms, one has to wonder about the effect on the many whose symptoms
are mild, intermittent or transient.
The other source is the drive to find disease early. While diagnoses
used to be reserved for serious illness, we now diagnose illness in
people who have no symptoms at all, those with so-called predisease or
those “at risk.”
Two developments accelerate this process. First, advanced technology
allows doctors to look really hard for things to be wrong. We can detect
trace molecules in the blood. We can direct fiber-optic devices into
every orifice. And CT scans, ultrasounds, M.R.I. and PET scans let
doctors define subtle structural defects deep inside the body. These
technologies make it possible to give a diagnosis to just about
everybody: arthritis in people without joint pain, stomach damage in
people without heartburn and prostate cancer in over a million people
who, but for testing, would have lived as long without being a cancer
patient.
Second, the rules are changing. Expert panels constantly expand what
constitutes disease: thresholds for diagnosing diabetes, hypertension,
osteoporosis and obesity have all fallen in the last few years. The
criterion for normal cholesterol has dropped multiple times. With these
changes, disease can now be diagnosed in more than half the population.
Most of us assume that all this additional diagnosis can only be
beneficial. And some of it is. But at the extreme, the logic of early
detection is absurd. If more than half of us are sick, what does it mean
to be normal? Many more of us harbor “pre-disease” than will ever get
disease, and all of us are “at risk.” The medicalization of everyday
life is no less problematic. Exactly what are we doing to our children
when 40 percent of summer campers are on one or more chronic
prescription medications?
No one should take the process of making people into patients lightly.
There are real drawbacks. Simply labeling people as diseased can make
them feel anxious and vulnerable — a particular concern in children.
But the real problem with the epidemic of diagnoses is that it leads to
an epidemic of treatments. Not all treatments have important benefits,
but almost all can have harms. Sometimes the harms are known, but often
the harms of new therapies take years to emerge — after many have been
exposed. For the severely ill, these harms generally pale relative to
the potential benefits. But for those experiencing mild symptoms, the
harms become much more relevant. And for the many labeled as having
predisease or as being “at risk” but destined to remain healthy,
treatment can only cause harm.
The epidemic of diagnoses has many causes. More diagnoses mean more
money for drug manufacturers, hospitals, physicians and disease advocacy
groups. Researchers, and even the disease-based organization of the
National Institutes of Health, secure their stature (and financing) by
promoting the detection of “their” disease. Medico-legal concerns also
drive the epidemic. While failing to make a diagnosis can result in
lawsuits, there are no corresponding penalties for overdiagnosis. Thus,
the path of least resistance for clinicians is to diagnose liberally —
even when we wonder if doing so really helps our patients.
As more of us are being told we are sick, fewer of us are being told we
are well. People need to think hard about the benefits and risks of
increased diagnosis: the fundamental question they face is whether or
not to become a patient. And doctors need to remember the value of
reassuring people that they are not sick. Perhaps someone should start
monitoring a new health metric: the proportion of the population not
requiring medical care. And the National Institutes of Health could
propose a new goal for medical researchers: reduce the need for medical
services, not increase it.
Dr. Welch is the author of “Should I Be Tested for Cancer? Maybe Not and
Here’s Why” (University of California Press). Dr. Schwartz and Dr.
Woloshin are senior research associates at the VA Outcomes Group in
White River Junction, Vt.
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Larry Scott
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