Sunday, June 8, 2014

Overdiagnosed

I recently read Overdiagnosed by Gilbert Welch, et al, (2011). 



GW makes a number of enlightening assertions in this book that represented significant new learning for me.  First, he argued that during the 1950s the emphasis in medical practice began shifting away from treating patients who were exhibiting concrete symptoms of disease, illness, and injury to attempts at "predicting" in patients (clients? customers?) the possible advent of disease or illness and intervening in an effort to mitigate the potential development of said ailments.  GW notes that via the ever-increasing sophistication and power of the technological tools used in determining diagnoses, physicians are able to "look harder" for potential health infractions.  He speaks specifically to the impact of these phenomena as they relate to prostate cancer, breast cancer, thyroid cancer, heart disease, etc., etc. 

GW uses several case studies to describe an effect he calls "cascading," in which a person (could be you, could be me) sees a physician about one ailment (perhaps chest pain), then, through a series of tests, screenings, scans, and biopsies has handed to them a whole litany of "abnormalities."  In fact, he describes many of these accidental findings as "incidentalomas." Thus, the patient (could be you, could be me) ends up being medicated, undergoes surgery, endures chemo- or radiation therapy, and/or other medical interventions to interdict these various and sundry illnesses (none of which were producing overt symptoms in the patient - could be you, could be me).  

GW argues rather convincingly, using concrete empirical data, that many folks who are diagnosed with these abnormalities (or even the ones who may be experiencing true early-stage symptoms) end up in worse health than if the patient and the physician were to simply stand down and observe as the body does its typical fight-the-enemy-off thing.  

GW notes a series of both intrinsic and extrinsic motivators that compel physicians to look harder, look longer, and look deeper for signs of disease/illness, or potential disease/illness. Those include: a genuine concern for patient health, the need to generate patient load in order to generate revenue, creating a "market" for sophisticated and expensive equipment (like MRI machines, CT scanners, etc.), pressure from big Pharma to prescribe new drugs, and the fear of litigation (of course!).

As I read the book, the names and faces of many of my friends and family came to mind as I began to wonder if they too had not fallen into this hamster cage of testing, diagnosis, treatment, re-testing, revised or different diagnosis, intervention, monitoring, changing of meds or subsequent surgery............................on and on it goes.

Welch argues that we have, and continue to operationalize, a system of overdiagnosis that harms more people than it actually helps.  

A good read. Extremely well written. Most informative. VERY thought provoking.

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