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 overlooked; and profits are being made from screenings, medical procedures, and pharmaceuticals. Revealing the social, medical, and economic ramifications of a health-care system that overdiagnoses and overtreats patients, Dr. H. Gilbert Welch makes a reasoned call for change that would save us pain, worry, and money.
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About the Author
Dr. H. Gilbert Welch is a renowned authority 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.
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.)
• 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).
Table of Contents
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
Most Helpful Customer Reviews
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.
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.
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.
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.
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!!
I see it all the time. One test leads to another. Sometimes to the point that the original complaint is overlooked.
Important book about the information age turning us all into patients. The PSA test for prostate cancer will serve as a quick example. Now that the test exists, men are told they should get it. A score of 2.5 or above is bad--cancer lurks. So everybody above 2.4 becomes a "cancer" patient. Their lives are changed forever. And people with 2.2? Not exactly likely to relax. What will next year's test bring? All this worry and fear despite the fact that prostate cancer is slow growing and kills approximately 3 out of 1000 males. This type of overdiagnoses occurs with breast cancer, thyroid cancer, lung cancer, etc. etc. We are living longer than ever, yet we think of ourselves as sicker than our parents thought of themselves. Way too much information! Welch suggests, in a nutshell, that unless you actually have symptoms, don't get caught up in the testing trap. I think it is great advice.