This week, I attended a provocative conference entitled Preventing Overdiagnosis: Winding Back the Harms of Too Much Care. Co-sponsored by Dartmouth University, British Medical Journal, Consumer Reports, and Australia’s Bond University, the conference raised many points that, at first glance, appear counterintuitive. After all, don't we have bigger issues with too little medical care?
Here are 7 of the most salient points that point the problems with too much care:
“Risk factors have been turned into diseases.” Dartmouth researcher Dr. Steve Woloshin discussed the absurdity of labeling us all with a “pre-disease”: doesn’t everyone all have some version of pre-hypertension, pre-diabetes, or even pre-death? And while screening can save lives, American Cancer Society’s Chief Medical Officer Dr. Otis Brawley uncovered the insidious practice hospitals offering “free” screening tests knowing that they will lead to false positives, thus creating a market for more testing and more care.
“Diseases are being created for the purpose of selling medications.” Physician-researcher Dr. Lisa Schwartz told the story of how GlaxoSmithKline created a new disease entity—restless leg syndrome—to find a new use of a Parkinson’s disease medication that was about to go off patent. Roy Moynihan showed his class spoof video of a new and dangerous epidemic.
“Ordinary experience is medicalized.” Dr. Allen Frances, a psychiatrist and Chair of the DSM4 task force, rails against the psychiatric profession for labeling people with diseases they don’t have. If you are grieving two weeks after the death of a spouse, you have depressive disorder; if your child is inquisitive and energetic, he has attention deficit disorder. To be sure, there are many cases of underdiagnoses, too, but many ordinary people are being labeled with diseases they don’t have.
“Language corrupts thought.” A diagnosis of “carcinoma-in-situ” brings up scary connotations and fuels the desire for aggressive treatment. However, our technologies have gotten so advanced that we are detecting many early cancers that, if left alone, may never grow or harm the patient. The National Cancer Institute recently proposed a change in terminology for cancer, and conference speakers proposed other disease definitions that should be changed to fully embrace the concept that disease is a spectrum, and not all disease causes harm.
“We are practicing faith-based medicine that ignores the harms and exaggerates the benefits.” It is well-documented that medical journals bias in favor of positive results, and that there are many financial interests to promote the newest, latest medication or treatment. Stories abound about people who survived because of early detection of disease and new, experimental treatment. However, there are also many stories of people who experience serious side effects and fatalities from overdiagnosis and overtreatment. These counternarratives need to be told, and evidence for harm needs to be published.
“Overdiagnosis is a symptom of the same problem that drives underdiagnosis and misdiagnosis.” In the discussion of overdiagnosis, it’s important not to forget that there are other pressing issues too, including medical error and lack of access to healthcare. The medical industrial complex is at fault here, too, and doctors need to assume our social responsibility and moral imperative to do what’s best for our patients.
“More care isn’t better care; it’s just more care.” In the words of cardiologist and Nobel Peace Prize winner Dr. Bernard Lown: “Overtreatment harms patients, thereby negating the first principle of doctoring, primum non nocere.” Our goal in medicine should be to do “as much as possible for the patient, as little as possible to the patient.”
So what can you do to ensure that you are receiving the right amount of care? Stay tuned; I will address this in my next article.
Be sure to read the following responses to this post by our bloggers: