The New York Times
Overdiagnosedby H. Gilbert Welch, Lisa M. Schwartz, Steven Woloshin
Going against the conventional wisdom reinforced by the medical establishment and Big Pharma that more screening is the best preventative medicine, Dr. Gilbert Welch builds a compelling counterargument that what we need are fewer, not more,/b>
From a nationally recognized expert, an exposé of the worst excesses of our zeal for medical testing
Going against the conventional wisdom reinforced by the medical establishment and Big Pharma that more screening is the best preventative medicine, Dr. Gilbert Welch builds a compelling counterargument that what we need are fewer, not more, diagnoses. Documenting the excesses of American medical practice that labels far too many of us as sick, Welch examines the social, ethical, and economic ramifications of a health-care system that unnecessarily diagnoses and treats patients, most of whom will not benefit from treatment, might be harmed by it, and would arguably be better off without screening.
Drawing on twenty-five years of medical practice and research on the effects of medical testing, Welch explains in a straightforward, jargon-free style how the cutoffs for treating a person with "abnormal" test results have been drastically lowered just when technological advances have allowed us to see more and more "abnormalities," many of which will pose fewer health complications than the procedures that ostensibly cure them. Citing studies that show that 10 percent of two thousand healthy people were found to have had silent strokes, and that well over half of men over age sixty have traces of prostate cancer but no impairment, Welch reveals overdiagnosis to be rampant for numerous conditions and diseases, including diabetes, high cholesterol, osteoporosis, gallstones, abdominal aortic aneuryisms, blood clots, as well as skin, prostate, breast, and lung cancers.
With genetic and prenatal screening now common, patients are being diagnosed not with disease but with "pre-disease" or for being at "high risk" of developing disease. Revealing the economic and medical forces that contribute to overdiagnosis, Welch makes a reasoned call for change that would save us from countless unneeded surgeries, excessive worry, and exorbitant costs, all while maintaining a balanced view of both the potential benefits and harms of diagnosis. Drawing on data, clinical studies, and anecdotes from his own practice, Welch builds a solid, accessible case against the belief that more screening always improves health care.
The New York Times
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.
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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
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.)
• Occasionally, I’ll get an intense burning sensation in my midchest after
eating or drinking. (Apple juice and apple cider are particularly problematic
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
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).
Meet the Author
Dr. H. Gilbert Welch is a professor at Dartmouth Medical School and a nationally recognized expert on the effects of medical testing. He has been published in the Los Angeles Times, New York Times, Washington Post, and Wall Street Journal, and has appeared on Today. In 2009, he received the Under Secretary's Award for Outstanding Achievement in Health Services Research.
Drs. Lisa Schwartz and Steven Woloshin are associate professors at Dartmouth.
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