Overdiagnosed: Making People Sick in the Pursuit of Health

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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 ...

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Overdiagnosed

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Overview

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.

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Editorial Reviews

From the Publisher
"Overdiagnosed —albeit controversial—is a provocative, intellectually stimulating work. As such, all who are involved in health care, including physicians, allied health professionals, and all current or future patients, will be well served by reading and giving serious thought to the material presented."─ JAMA

“Everyone should read this book before going to the doctor! Welcome evidence that more testing and treatment is not always better.”─ Susan Love, MD, author of Dr. Susan Love’s Breast Book
 
“This book makes a compelling case against excessive medical screening and diagnostic testing in asymptomatic people. Its important but underappreciated message is delivered in a highly readable style. I recommend it enthusiastically for everyone.”─ Arnold S. Relman, MD, editor-in-chief emeritus, New England Journal of Medicine, and author of A Second Opinion: Rescuing America’s Health Care
 
“This stunning book will help you and your loved ones avoid the hazards of too much health care. Within just a few pages, you’ll be recommending it to family and friends, and, hopefully, your local physician. If every medical student read Overdiagnosed, there is little doubt that a safer, healthier world would be the result.”─ Ray Moynihan, conjoint lecturer at the University of Newcastle, visiting editor of the British Medical Journal, and author of Selling Sickness
 
“An ‘overdiagnosis’ is a label no one wants: it is worrisome, it augurs ‘overtreatment,’ and it has no potential for personal benefit. This elegant book forewarns you. It also teaches you how and why to ask, ‘Do I really need to know this?’ before agreeing to any diagnostic or screening test. A close read is good for your health.”─ Nortin M. Hadler, MD, professor of medicine and microbiology/immunology at University of North Carolina at Chapel Hill and author of Worried Sick and The Last Well Person
 
“We’ve all been made to believe that it is always in people’s best interest to try to detect health problems as early as possible. Dr. Welch explains, with gripping examples and ample evidence, how those who have been overdiagnosed cannot benefit from treatment; they can only be harmed. I hope this book will trigger a paradigm shift in the medical establishment’s thinking.” —Sidney Wolfe, MD, author of Worst Pills, Best Pills and editor of WorstPills.org

Kirkus Reviews

Three medical practitioners concerned about the impact of increased use of diagnostic screening tools address the underlying causes and present their prescription.

Welch, Schwartz and Woloshin—professors at the Dartmouth Institute for Health Policy and Clinical Practice—assert that too many Americans are receiving unnecessary treatment for so-called abnormalities that are prevalent in the population but cause no symptoms, and thus no harm. Due to the increased use of high-tech diagnostic tools and a corresponding lowering of diagnostic thresholds, more of us are being told we meet the criteria for conditions and diseases that warrant intervention. The authors recognize that they are presenting a tough platform—isn't it better, conventional wisdom states, to find and prevent high blood pressure or prostate cancer before actual onset of symptoms?—but their point is that it can be costly and even harmful. Potential problems become magnified, increasing numbers of people are labeled as patients and the side effects of many medications may generate more problems then they alleviate. Overdiagnosis leads to overtreatment, write the authors, who ask readers to look closely at claims that testing will save lives—e.g., "most women will not benefit from mammography—for example, about two thousand forty-year-old women need to be screened over ten years for one woman to benefit." The authors do a fine job incorporating relevant medical terminology to bolster their argument. However, because citing randomized trials and rational risk estimates doesn't hold great emotional weight, they also share their own common-sense observations as well as a body of research culled from many sources. The tone is sensible and serious but reassuring, and the authors make a strong case for moderation.

An antidote to alarmist thinking about the prevalence of disease.

Abigail Zuger
One of the big strengths of this relatively small book is that if you are inclined to ponder medicine's larger questions, you get to tour them all. What is health, really? Why do we sometimes equate "normal" with "desirable" when it often means just the opposite? In the finite endeavor that is life, when is it permissible to stop preventing things? And if the big questions just make you itchy, you can concentrate on the numbers instead: The authors explain most of the important statistical concepts behind evidence-based medicine in about as friendly a way as you are likely to find.
—The New York Times
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Product Details

  • ISBN-13: 9780807022009
  • Publisher: Beacon
  • Publication date: 1/18/2011
  • Pages: 248
  • Product dimensions: 6.20 (w) x 9.00 (h) x 0.90 (d)

Meet the Author

Dr. H. Gilbert Welch is a nationally recognized expert on the effects of medical screening who has appeared on The Today Show, CNN, NPR, and in the New York Times and Washington Post. He and his coauthors, Dr. Lisa M. Schwartz and Dr. Steven Woloshin, nationally recognized experts in risk communication, are professors at the Dartmouth Institute for Health Policy and Clinical Practice.

 

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Read an Excerpt

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).

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Table of Contents

Introduction: Our Enthusiasm for Diagnosis

Chapter 1) Genesis: People Become Patients with High Blood Pressure
Chapter 2) We Change the Rules: How Numbers Get Changed to Give You Diabetes, High Cholesterol, and Osteoporosis
Chapter 3) We Are Able to See More: How Scans Give You Gallstones, Damaged Knee Cartilage, Bulging Discs, Abdominal Aortic Aneurysms, and Blood Clots
Chapter 4) We Look Harder for Prostate Cancer: How Screening Made It Clear That Overdiagnosis Exists in Cancer
Chapter 5) We Look Harder for Other Cancers
Chapter 6) We Look Harder for Breast Cancer
Chapter 7) We Stumble onto Incidentalomas That Might Be Cancer
Chapter 8) We Look Harder for Everything Else: How Screening Gives You (and Your Baby) Another Set of Problems
Chapter 9) We Confuse DNA with Disease: How Genetic Testing Will Give You Almost Anything
Chapter 10) Get the Facts
Chapter 11) Get the System
Chapter 12) Get the Big Picture

Conclusion: Pursuing Health with Less Diagnosis

Acknowledgments
Notes
Index

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Customer Reviews

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  • Posted March 3, 2011

    more from this reviewer

    Medical Alert!

    Overdiagnosed: Making People Sick in the Pursuit of Health by Dr. H. Gilbert Welch is worthwhile reading for those interested in health and wellness. It gives easy-to-understand information on hypertension/high blood pressure, systolic reading, diastolic reading, randomized studies, what is abnormal, and what certain numbers mean. Inside you will learn about how diabetes and high cholesterol are diagnosed as well as how some patients are "overdiagnosed" for different illnesses and disease. You'll learn about "catching" an illness early before symptoms develop and why treatment is encouraged before symptoms occur. Find out what "cutoffs" and "thresholds" are. Dr. Welch explains how medical experts have "changed the rules," thus changing the number of people with certain illnesses and disease. There are definitions offered for many illnesses other than hypertension/high blood pressure, high cholesterol, and diabetes that you will read about as well, if you choose to read Dr. Welch's findings. Chapter 10 "Get the Facts" is great! - it is rather enlightening reading. This book is informative and educational.

    3 out of 3 people found this review helpful.

    Was this review helpful? Yes  No   Report this review
  • Posted February 7, 2011

    Everyone should read this book!

    Dr. Welch and his colleagues have produced a book that will open your eyes to the unquestioned belief in "early diagnosis" and what this actually means to your long-term health. Truth is multiple forces (Big Pharma, "true believers", doctors' fear of being sued, medical device manufacturers) have promoted "early diagnosis" as a Holy Grail, with little evidence that supports its value. We push screening blood tests, bone density scans, PSAs supposedly to find to find an abnormality "early". The result is that there is an epidemic of overdiagnosis, which means an abnormality with no symptoms. Identifying an abnormality ever earlier is of little value in terms of long-term outcome. However, it does turn you into a patient, subjects you to medications and procedures of little value. Although Dr. Welch makes these concepts clear, this isn't an especially easy read. You'll need to think and contemplate the charts and graphs. You'll be glad you did. The next time you're offered a screening test when you have no symptoms, you'll know the back story, both the minor pros and the very large cons of unquestioned belief in the value of "early diagnosis." By the way, Dr. Welch and his co-authors are not "alternative medicine" practitioners. They are well-respected, well-credentialed, experienced academic physicians.

    2 out of 2 people found this review helpful.

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  • Posted February 1, 2011

    Buy one copy for yourself and another for your doctor!

    I read Overdiagnosed this morning, and I strongly urge you to read it, too. If you've ever wondered why our country's healthcare costs are skyrocketing even though our health outcomes lag behind the rest of the industrialized world, this book has the answers. We are overtested, overdiagnosed and overtreated. But sadly and paradoxically, this intensive use of "preventive" medicine has not improved our physical health or sense of well being -- it has diminished it.

    Dr. Welch builds a strong case that Americans are overdiagnosed in a clear, concise and compelling way. He provides anecdotal accounts of people who were seriously harmed by the overzealous use of modern, high tech testing. And he backs these stories up with findings from landmark medical research studies. As we move from chapter to chapter and disease to disease, we see the same patterns emerge: thresholds for "illness" are lowered and suddenly tens of millions of people are diagnosed and treated for mild or nonexistent "diseases" that never would have harmed them.

    Dr. Welch identifies the key players who brought American medicine to this sorry state -- big pharma and medical products manufacturers hungry to increase profits, doctors who order unnecessary tests to avoid malpractice lawsuits, and overzealous patient advocacy groups who press for action in the absence of any scientific evidence of improved outcomes.

    Dr. Welch explains key concepts like "lag time bias" and "overtreatment bias" that enable you to see why the benefits of aggressive preventive medicine are far less than you have been led to believe. Once you understand terms like these, you will never again be swayed by misleading advertising or public health campaigns. Instead, you will be able to make decisions about your own health care in a rational, intelligent, and informed way.

    In short, if you read one health related book this year, it should be "Overdiagnosed." Buy one copy for yourself and another for your doctor.

    2 out of 2 people found this review helpful.

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  • Anonymous

    Posted December 9, 2012

    READ THIS BOOK!!!!! Personally, I have been caught up in the en

    READ THIS BOOK!!!!!

    Personally, I have been caught up in the endless cycle of testing for no good reason and am fed up!! I borrowed this from the library but will be purchasing a copy of my own for future reference!!

    1 out of 1 people found this review helpful.

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  • Posted February 18, 2012

    excellent-highly recommend

    As a pharmacist, I was already skeptical about our current healthcare system. After reading this book, I will change how I interact with the system. We each need to make our own individual choices as to whether or not we should pursue therapy. Our choices would be made much easier if we received better estimates of the real risks and benefits. Dr Welch looks at many common medical problems and tries to elucidate the probability of benefit versus non-monetary costs which are seldom considered.

    1 out of 1 people found this review helpful.

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