If You Feel OK, Maybe You Are OK

Early diagnosis has become one of the most fundamental precepts of modern medicine. It goes something like this: The best way to keep people healthy is to find out if they have (pick one) heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or, of course, cancer — early. And the way to find these conditions early is through screening.

It is a precept that resonates with the intuition of the general public: obviously it’s better to catch and deal with problems as soon as possible. A study published with much fanfare in The New England Journal of Medicine last week contained what researchers called the best evidence yet that colonoscopies reduce deaths from colon cancer.

Recently, however, there have been rumblings within the medical profession that suggest that the enthusiasm for early diagnosis may be waning. Most prominent are recommendations against prostate cancer screening for healthy men and for reducing the frequency of breast and cervical cancer screening. Some experts even cautioned against the recent colonoscopy results, pointing out that the study participants were probably much healthier than the general population, which would make them less likely to die of colon cancer. In addition there is a concern about too much detection and treatment of early diabetes, a growing appreciation that autism has been too broadly defined and skepticism toward new guidelines for universal cholesterol screening of children.

The basic strategy behind early diagnosis is to encourage the well to get examined — to determine if they are not, in fact, sick. But is looking hard for things to be wrong a good way to promote health? The truth is, the fastest way to get heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or cancer … is to be screened for it. In other words, the problem is overdiagnosis and overtreatment.

Screening the apparently healthy potentially saves a few lives (although the National Cancer Institute couldn’t find any evidence for this in its recent large studies of prostate and ovarian cancer screening). But it definitely drags many others into the system needlessly — into needless appointments, needless tests, needless drugs and needless operations (not to mention all the accompanying needless insurance forms).

This process doesn’t promote health; it promotes disease. People suffer from more anxiety about their health, from drug side effects, from complications of surgery. A few die. And remember: these people felt fine when they entered the health care system.

It wasn’t always like this. In the past, doctors made diagnoses and initiated therapy only in patients who were experiencing problems. Of course, we still do that today. But increasingly we also operate under the early diagnosis precept: seeking diagnosis and initiating therapy in people who are not experiencing problems. That’s a huge change in approach, from one that focused on the sick to one that focuses on the well.

Think about it this way: in the past, you went to the doctor because you had a problem and you wanted to learn what to do about it. Now you go to the doctor because you want to stay well and you learn instead that you have a problem.

How did we get here? Or perhaps, more to the point: Who is to blame? One answer is the health care industry: By turning people into patients, screening makes a lot of money for pharmaceutical companies, hospitals and doctors. The chief medical officer of the American Cancer Society once pointed out that his hospital could make around $5,000 from each free prostate cancer screening, thanks to the ensuing biopsies, treatments and follow-up care.

A more glib response to the question of blame is: Richard Nixon. It was Nixon who said, “we need to work out a system that includes a greater emphasis on preventive care.” Preventive care was central to his administration’s promotion of health maintenance organizations and the war on cancer. But because the promotion of genuine health — largely dependent upon a healthy diet, exercise and not smoking — did not fit well in the biomedical culture, preventive care was transformed into a high-tech search for early disease.

Some doctors have long recognized that the approach is a distraction for the medical community. It’s easier to transform people into new patients than it is to treat the truly sick. It’s easier to develop new ways of testing than it is to develop better treatments. And it’s a lot easier to measure how many healthy people get tested than it is to determine how well doctors manage the chronically ill.

But the precept of early diagnosis was too intuitive, too appealing, too hard to challenge and too easy to support. The rumblings show that that’s beginning to change.

Let me be clear: early diagnosis is not always wrong. Doctors would rather see patients early in the course of their heart attack than wait until they develop low blood pressure and an irregular heartbeat. And we’d rather see women with small breast lumps than wait until they develop large breast masses. The question is how often and how far we should get ahead of symptoms.

For years now, people have been encouraged to look to medical care as the way to make them healthy. But that’s your job — you can’t contract that out. Doctors might be able to help, but so might an author of a good cookbook, a personal trainer, a cleric or a good friend. We would all be better off if the medical system got a little closer to its original mission of helping sick patients, and let the healthy be.

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. He is the co-author of Overdiagnosed: Making People Sick in the Pursuit of Health. This post originally appeared in the New York Times.

6 replies »

  1. As with most of the issues in healthcare, the problem is one of balance.

    There is a huge benefit from having access to advanced technology and the ability to detect problems before they become symptomatic or advanced. The challenge is remembering what we’re doing it all for. The goal is to live well, to have healthy and productive lives for as long as we can, and to not be crazy while trying to get it.

    This is not a theoretical discussion.

    A few years ago, I spent several weeks flying around the country. I ended up with severe low back pain and had an MRI done. My doctor told me I had some inflammation of the lumbar vertebrae but no slipped disc. What I found out, though, was that I also had a pretty sizable ovarian cyst. I had it evaluated, monitored for a few months, and eventually removed when it didn’t resolve. Although it wasn’t malignant (thank god), I was grateful for the ‘incidental finding’ that let me get it managed before something possibly did change.

    But the other side of the argument is equally true.

    If I had developed a complication from surgery, I would have had to reconcile the fact I chose to have a procedure just in case the cyst was something bad, and I would have had to accept that I had a negative outcome when I didn’t need to have had anything done at all.

    Moreover, in a society of limited resources (and that’s what much of economics is – a study of the management of limited resources), we have to decide how we want to manage what we have. Not only does initial screening lead to a fair amount of expensive and sometimes unnecessary follow up that physicians feel compelled to do and patients feel is needed for peace of mind, some of the invasive procedures carry their own risks. As any doctor or patient who has had to make the decision for themselves know, it’s a tough process to weigh the risks and benefits.

    The trouble is that when we have the ability to find the ‘silent killers’ before they do their damage, why wouldn’t we want to? At the end of the day, I think it’s about balance and nuance, a mix of knowing statistical probabilities and keeping perspective. It’s about not having it become about money for hospitals and providers, and preventing liability for physicians.

    And, of course, it’s about people taking the actions that we all know we should and living our lives in the best way possible.

  2. Although I generally rail against governmental interference in medicine, this is one area where government has a clear role – and )of course…) is not fulfilling it.

    There is great value in _selective_ screening for a relatively small number of diseases. But in order for that statement to apply, there must exist the right combination of disease incidence/prevalence, population characteristics, screening selectivity and specificity and treatability. The proper combination of these characteristics is unknown for most diseases – and this is where the government can/should step in. Determining the ideal criteria is difficult, time consuming and expensive – factors that cry out for government funding, because commercial interests don’t see the short term profitability necessary to justify these expenditures, and non-corporate interests simply don’t have access to enough patients to do the job.

    Whether government will take on these efforts is questionable. The “political payoff” for this type of research is low – no headlines touting how wonderful the sponsoring agency/politician is, no mass employment of voters, and no plethora of labs in each of several different legislative districts. But without research to define the appropriate criteria for screening exams, they will continue to be used by commercial health care interests to herd the anxious into the eagerly awaiting arms of for-profit health care entities.

  3. The role of the industry – especially the pharmaceutical industry – cannot be overstated (we see that particularly in “raising awareness” campaigns for conditions that hardly make anyone miserable, and/or are not really treatable) . But very many patients are – unbeknownst to them – accomplices, requesting testing and therapy for symptoms that are negligible. And the unfortunate nature of the beast is that many concerning conditions start with minor, negligible symptoms … but priorities in the US are wrong when in most doctors offices, minor symptoms are triggers of panendoscopy or extensive scanning. In the US, we do too much (for patients having insurance) and are getting too little out of it.

  4. This is an interesting article. I agree that there are means to prevention that are not as complicated, costly, and sometimes invasive as medical screenings. I recently wrote a short, general post on prevention in my health blog that supports the health benefit of a healthy diet, exercise, spiritual counseling, or support systems such as friends.

  5. Interesting. Ahh.. the Gnarled Nexus of Prevalence, Sensitivity, Specificity, and Bayes.

    I will have to buy your book.

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