Tuesday, August 30, 2011

Book Reviews: "Over-Diagnosed" and "Worried Sick"

These two books -- one recently published, the other dating back to 2008 -- raise profound questions about current medical practices, and conclude that the healthcare system is often causing far more harm than good. Most people in the healthcare industry are unlikely to agree with these authors—otherwise these books wouldn't have had to be written—but both are authored by highly-respected doctors with deep experience, and they resonate strongly with me.

In Over-Diagnosed: Making People Sick in the Pursuit of Health (2011), Dr. Gilbert Welch, and co-authors Dr. Lisa Schwartz and Dr. Steven Woloshin, write that “[they] believe overdiagnosis is the biggest problem posed by modern medicine.” Overdiagnosis is defined as “when individuals are diagnosed with conditions that will never cause symptoms or death.” Which means that “there’s nothing to be fixed—[the patient] will neither develop symptoms nor die from his condition—so treatment is unneeded. An overdiagnosed patient can only be harmed.”

The authors point out that the medical community has been constantly moving the goalposts, changing the threshold at which a person is labeled as having some medical condition, such that ever more people are diagnosed. For example, a person was once said to have diabetes when his fasting blood sugar level was 140. When the threshold was changed to 126 an additional 14% of the population was defined as having diabetes. Similar changes in thresholds have led to a 35% increase in hypertension, a 86% in hyperlipidemia (high cholesterol), and a 85% increase in osteoporosis in women.

The consequences are enormous, write the authors: "[Overdiagnosis] has led millions of people to become patients unnecessarily, to be made anxious about their health, to be treated needlessly, and to bear the inconvenience and financial burdens associated with overdiagnosis. It has added staggering costs to our already overburdened healthcare system." The authors also note enormous obstacles to fixing the problem: financial gains from all the unneeded treatments; blind faith amongst doctors in existing practices; a legal environment that punishes under-treatment but not over-treatment; and popular media that promotes the types of practices that the book decries.

In Worried Sick: A Prescription for Health in an Overtreated America (2008), Dr. Nortin Hadler writes that “we are at grave risk of what I call 'Type II Medical Malpractice'—doctors doing the unnecessary, albeit very well (as opposed to Type I Medical Malpractice, which is doctors doing the necessary unacceptably poorly.)”

Hadler argues that we must change our social perceptions of what it means to be well, that we should not medicalize every deviation from some imagined state of perfect health. “To be well is not to be free of symptoms—of morbidity—continuously or for long periods of time," he writes. "It is abnormal to escape heartburn and heartache, backache and headache, sad days and days when we’re aware of our bowels...we are challenged to cope with these predicaments of life and of living.”

Hadler labels himself a "revolutionary," and uses strong language to denounce many widely accepted medical practices as a “vast marketplace for unnecessary and unproven remedies” and what he terms “disease mongering.” Not only do doctors treat us unnecessarily and inappropriately, they make it more difficult for us to be well. “To be well is to be able to cope with morbid episodes. And coping may not be easy. It can be thwarted by the intensity of the morbidity, or by complicating and confounding factors,” continues Hadler. Standard medical advice, which makes you worry that you are sick, being one of the major confounding factors.

Both books urge that there should be much less “medicalization” of the normal ups and downs of health, and that more efforts be focused on helping people cope, without drama. In Over-Diagnosed, Welch concludes: “[H]ealth-promotion efforts need to be judged using a broader set of parameters than is traditionally used for medical care. My coauthors and I would rank highest those health-promotion efforts that lead people to feel more resilient, either physically or emotionally. By resilient I mean feeling strong, able to participate in and enjoy the life you lead—and capable of meeting and dealing with adversity when it comes.”

Both of these books resonated strongly with me. The more I have looked into the science behind today's healthcare practices, the more I have learned how weak the foundation is. Skilled doctors are certainly in a far better position than the average lay person to deal with medical emergencies. But, for day-to-day health we would be much better off discarding simplistic health rules, and instead empowering and enabling people to lead themselves, to "cope" as Dr Hadler puts it, or to be "resilient" as Dr Welch says.

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