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Summary
Summary
From a nationally recognized expert, an exposé of the worst excesses of our zeal for medical testing
After the criteria used to define osteoporosis were altered, seven million American women were turned into patients--literally overnight. The proliferation of fetal monitoring in the 1970s was associated with a 66 percent increase in the number of women told they needed emergency C-sections, but it did not affect how often babies needed intensive care--or the frequency of infant death. The introduction of prostate cancer screening resulted in over a million additional American men being told they have prostate cancer, and while studies disagree on the question of whether a few have been helped--there's no disagreement that most have been treated for a disease that was never going to bother them. As a society consumed by technological advances and scientific breakthroughs, we have narrowed the definition of normal and increasingly are turning more and more people into patients. Diagnoses of a great many conditions, including high blood pressure, osteoporosis, diabetes, and even cancer, have skyrocketed over the last few decades, while the number of deaths from those diseases has been largely unaffected.
Drawing on twenty-five years of medical practice and research, Dr. H. Gilbert Welch and his colleagues, Dr. Lisa M. Schwartz and Dr. Steven Woloshin, have studied the effects of screenings and presumed preventative measures for disease and "pre-disease." Welch argues that while many Americans believe that more diagnosis is always better, the medical, social, and economic ramifications of unnecessary diagnoses are in fact seriously detrimental. Unnecessary surgeries, medication side effects, debilitating anxiety, and the overwhelming price tag on health care are only a few of the potential harms of overdiagnosis.
Through the stories of his patients and colleagues, and drawing from popular media, Dr. Welch illustrates how overdiagnosis occurs and the pitfalls of routine tests in healthy individuals. We are introduced to patients such as Michael, who had a slight pain in his back. Despite soon feeling fine, a questionable abnormal chest X-ray led to a sophisticated scan that detected a tiny clot in his lung. Because it could not be explained, his doctors suggested that it could be a sign of cancer. Michael did not have cancer, but he now sees a psychiatrist to deal with his anxiety about cancer.
According to Dr. Welch, a complex web of factors has created the phenomenon of overdiagnosis: the popular media promotes fear of disease and perpetuates the myth that early, aggressive treatment is always best; in an attempt to avoid lawsuits, doctors have begun to leave no test undone, no abnormality--no matter how incidental--overlooked; and, inevitably, profits are being made from screenings, a wide array of medical procedures, and, of course, pharmaceuticals. 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.
Reviews (2)
Booklist Review
*Starred Review* Health policy expert Welch's assertions about the benefits of some of modern medicine's most popular diagnostic screening tools are unlikely to ingratiate him with many people. He claims that overdiagnosis is the biggest problem posed by modern medicine, and backs that assertion up with a barrage of facts, charts, and graphs. This is information, he says, that is downplayed or simply ignored by individuals and groups promoting the notion that earlier diagnosis whether for prostate cancer or diabetes translates to better health. Indeed, Welch says, just the converse is more often true. In an overwhelming number of circumstances, early diagnosis turns healthy, asymptomatic people into patients who require a variety of medical interventions with no benefit, even exposing them to unnecessary harm. Worse, overdiagnosis can render perfectly healthy people uninsurable. Furthermore, instead of lowering health-care costs, all those scans, screenings, and tests actually raise costs by overtreating people who will never benefit from said treatment. His point is that both physicians and patients need to be skeptical and understand all the data (pro and con) surrounding prescreening for possible illness. Welch speaks his truth with a frankness and clarity scant found in today's hysteria over medical prescreening.--Chavez, Donna Copyright 2010 Booklist
Choice Review
As a physician with expertise in medical screening procedures, Welch, along with his physician-coauthors, examines the consequences of overdiagnosis for consumers in the US health care system. The authors argue that the expansion of screening procedures and the redefining of some measures and characteristics of medical abnormalities have led to the "biggest problem posed by modern medicine"--overdiagnosis of disease and the growing designation of people as patients. Recognizing that some diagnoses lead to unnecessary treatments, Welch and colleagues studied the medical, social, and economic consequences of too many patients being diagnosed with predisease, sometimes without symptoms, and experiencing unnecessary treatments that often caused more harm than relief. Using clearly written case studies of patients, the authors examine the processes and procedures that have shifted medical care from treatment for those who are sick to prevention and early disease detection for those who may not be ill but are subjected to treatments. Suggesting that a paradigm shift is necessary, they offer steps toward critically considering early diagnosis in the context of illness and treatment and toward focusing on health promotion. Summing Up: Recommended. Upper-level undergraduates and above; general readers. M. P. Tarbox Mount Mercy University
Excerpts
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). Excerpted from Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwartz, Steven Woloshin All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.Table of Contents
| Introduction: Our Enthusiasm for Diagnosis | p. ix |
| Chapter 1 Genesis: People Become Patients with High Blood Pressure | p. 1 |
| Chapter 2 We Change the Rules: How Numbers Get Changed to Give You Diabetes, High Cholesterol, and Osteoporosis | p. 15 |
| Chapter 3 We Are Able to See More: How Scans Give You Gallstones, Damaged Knee Cartilage, Bulging Discs, Abdominal Aortic Aneurysms, and Blood Clots | p. 32 |
| Chapter 4 We Look Harder for Prostate Cancer: How Screening Made It Clear That Overdiagnosis Exists in Cancer | p. 45 |
| Chapter 5 We Look Harder for Other Cancers | p. 61 |
| Chapter 6 We Look Harder for Breast Cancer | p. 73 |
| Chapter 7 We Stumble onto Incidentalomas That Might Be Cancer | p. 90 |
| Chapter 8 We Look Harder for Everything Else: How Screening Gives You (and Your Baby) Another Set of Problems | p. 102 |
| Chapter 9 We Confuse DNA with Disease: How Genetic Testing Will Give You Almost Anything | p. 116 |
| Chapter 10 Get the Facts | p. 136 |
| Chapter 11 Get the System | p. 151 |
| Chapter 12 Get the Big Picture | p. 167 |
| Conclusion: Pursuing Health with Less Diagnosis | p. 180 |
| Acknowledgments | p. 192 |
| Notes | p. 194 |
| Index | p. 218 |