By John Hendrickson
As the future of the Patient Protection and Affordable Care Act (Obamacare) awaits its judgment by the United States Supreme Court, policymakers and individuals need to begin looking at different policies and ideas to not only reduce the cost of health care, but also improve the quality of service. In Over-Diagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch and co-authors Dr. Lisa M. Schwartz and Dr. Steven Woloshin discuss the nature of overdiagnosis, which “is the biggest problem posed by modern medicine. It is a problem relevant to virtually all medical conditions.”[1]The authors argue that “this book is about the relentless expansion of medicine and our increasing tendency to make diagnoses.”[2]
Though many policy problems confront health care in the United States, our nation still has the best health-care service in the world. The American health-care system provides not only quality care, but also an economic system that encourages growth in technology along with research and development in order to increase the quality of treatment. Health care is a large part of our culture. Our society is inundated with health/medical ads on media outlets across-the-board that encourage healthy living, early screening, and new medications, among many others. As the authors of Over-Diagnosed explain:
Americans have been trained to be concerned about our health. All sorts of hidden dangers lurk inside us. The conventional wisdom is that it’s always better to know about these dangers so that something can be done… That’s why we are so enthusiastic about amazing medical technologies that can detect abnormalities even when we think we are well. That’s also why we welcome the identification of risk factors, disease-awareness campaigns, cancer screenings, and genetic testing. Americans love diagnosis, especially early diagnosis.[3]
This is where the problem of overdiagnosis becomes an issue in our health-care system. “Overdiagnosis is a relatively new problem in medicine,” as the authors note:[4]
In the past, people didn’t go to the doctor when they were well — they tended to wait until they developed symptoms. Furthermore, doctors didn’t encourage the healthy to seek care. The net result was that doctors made fewer diagnoses than they do now. But the paradigm has changed. Early diagnosis is the goal. People seek care when they are well. Doctors try to detect disease earlier.[5]
Some of the examples that the authors write about in the book include hypertension (high blood pressure) and diabetes. In regard to hypertension, “before the late 1990s, a blood pressure reading of 160-over-100 was considered the threshold for the diagnosis…; today it is 140-over-90.”[6] A similar situation applies to blood sugar numbers when diagnosing diabetes. Welch notes that when he was “in medical school,” a “fasting blood sugar over 140” was a diagnosis for diabetes, but today that number has been lowered to 126 as a result of a special committee.[7]
This change in diagnosing both hypertension and diabetes can be both good and problematic:
So everyone who has a blood sugar between 126 and 140 used to be normal but now has diabetes. That little change turned over 1.6 million people into patients. Is that a problem? Maybe, maybe not. Because we changed the rules, we now treat more patients for diabetes. That may mean we have lowered the chance of diabetic complications for some of these new patients. But because these patients have milder diabetes, they are relatively low risk for these complications to begin with. So just like people with relatively mild hypertension, people with mildly abnormal blood sugar levels have less to gain from treatment.[8]
The authors argue that “the problem of overdiagnosis stems directly from the expansion of the pool of individuals in whom we make diagnoses: from individuals with disease (those with symptoms) to individuals with abnormalities (those without symptoms).”[9] In addition, they argue that “all treatments have the potential to do some harm,” but a patient who is “overdiagnosed cannot benefit from treatment. There’s nothing to be fixed…”[10]
Throughout the book the authors are careful not to dismiss the seriousness of diagnosis, “especially for those who are sick.” Nor is it an endorsement for “alternative medicine,” but rather “for the many who are (or used to be) basically well — or those who have one illness and are at risk of being told they have others.”[11] “The question I’m raising is not whether you should seek out a doctor — and a diagnosis — when you are sick…The question is about when you are well. How hard should a doctor look for things to be wrong?” asked Welch[12]
Over-Diagnosed provides a serious overview of a problem that confronts health care from all directions. The thesis of the book provides a synopsis of why overdiagnosis is a crucial issue:
It is a problem relevant to virtually all medical conditions. It 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 health-care system. And all of the forces that helped create and exacerbate the problem — financial gain, true belief, legal concerns, media messages, and self-reinforcing cycles — are powerful obstacles to fixing it.[13]
Endnotes:
[1] Dr. H. Gilbert Welch, Dr. Lisa M. Schwartz, and Dr. Steven Woloshin, Over-Diagnosed: Making People Sick in the Pursuit of Health, Beacon Press, Boston, Massachusetts, 2011, p. 180.
[2] Ibid., p. xii.
[3] Ibid.
[4] Ibid., p. xiv.
[5] Ibid., pp. xiv-xv.
[6] Peter Van Doren, “The Second Wave of Managed Care?” Regulation, Vol. 34, No. 4, Cato Institute, Washington, D.C., Winter 2011-2012, p. 41.
[7] Welch, Schwartz, and Woloshin, pp. 17-18.
[8] Ibid., p. 18.
[9] Ibid., p. xv.
[10] Ibid.
[11] Ibid.
[12] Ibid., p. 180.
[13] Ibid.
John Hendrickson is a Research Analyst with Public Interest Institute in Mount Pleasant, Iowa. Republished by permission from INSTITUTE BRIEF, a publication of Public Interest Institute.