Over-diagnosis & Over-treatment
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Over-diagnosis
Over-diagnosis is when a medical professional diagnoses a condition that would not have caused symptoms or death in the patient. It can also refer to the detection of a condition without any possible benefit of early treatment.
The biggest problem is that over-diagnosis triggers over-treatment which can actually do harm. Here is an NIH article for physicians on over-diagnosis. Here is a link to an interview with Dr. Gilbert Welch, , a professor of medicine and director of the Center for Medicine and the Media at the Dartmouth Institute for Health Policy and Clinical Practice.
Here is an example of how over treatment can do damage. The poster child for the problem is prostate cancer screening: 20 years ago, a “simple blood test” was introduced; 20 years later, over one million Americans had been treated for a cancer that was never going to bother them. The test was the PSA. It’s able to detect minute quantities of prostate-specific antigen—minute as in one-billionth of a gram. Turned out a lot of men had “abnormal” PSAs. Many were found to have microscopic cancers—far more than would ever suffer from prostate cancer. So they were over-diagnosed.
Does it matter? Absolutely. Most were treated with either radical surgery or radiation. Roughly a third suffered side effects of treatment—generally related to bowel, bladder, or sexual function. And a few have died from it. Across all ages testing results in one saved life in 1000 (Harvard reference).
Regarding high blood pressure, high cholesterol, and diabetes there is a similar story. These conditions can be important and that treatment can help—i.e., treating really high blood pressure is one of the most important things doctors can do. But the “rule” by which health conditions are gauged—the number which, if you are on one side of it, you are well, but if you are on the other side of it, you are sick—has been regularly changing. For example, a fasting blood sugar of 130 was not considered to be diabetes before 1997, but now it is. And these numbers are always changing in one direction: the direction of labeling more and more people as abnormal.
The problem is that these newly created patients stand to benefit the least from intervention. Yet they face roughly the same amount of harm from intervention. In other words, the net effect of intervention may be harm. For example, with diabetes, while trying to move people with mildly elevated blood sugars towards “normal,” the death rate increased.
There is an issue of balance. Doctors tend to focus on the one out of a thousand but not always on the other 999 for whom treatment may be useless and cause real harm.
Who Benefits?
Drug makers, pharmacy benefit managers, device manufacturers, imaging centers, and even your local hospital all benefit from increased testing and treatment. The easiest way to make money isn’t to build a better drug or device—it’s to expand the market for existing drugs and devices by expanding the indication to include more patients. Similarly, for hospitals, the easiest way to make money isn’t to deliver better care; it’s to recruit new patients—and screening is a great way to do this.
Screening everyone, while it seems prudent on the surface, can cause harm. Part of the issue is that there is a legal imbalance. Doctors are punished for not diagnosing but never punished for over-diagnosing.
Patients can be offered testing for various conditions, based on family history or other indicators. Professor Welch recommended that there are choices and that the decision to look for something wrong is not a “no-brainer”. He recommends patients understand both sides of the issue, the risks and the benefits so that they and their doctor can make an informed decision.
Here are 5 groups of questions recommend for a patient /doctor discussion by Choosing Wisely:
Do I really need this test or procedure?
Medical tests help you and your doctor or other health provider decide how to treat a problem. And medical procedures help to actually treat it.
What are the risks? Will there be side effects? What are the chances of getting results that aren’t accurate? Could that lead to more testing or another procedure?
Are there simpler, safer options?
Sometimes all you need to do is make lifestyle changes, such as eating healthier food or exercising more.
What happens if I don’t do anything? Ask if your condition might get worse — or better — if you don’t have the test or procedure right away.
How much does it cost? Ask if there are less-expensive tests, treatments or procedures, what will your insurance pay for it?
Here is a link to Choosing Wisely recommendations on the American Academy of Family Physicians website.
Here is a link to the Choosing Wisely site. Let’s be better consumers.
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It’s not always ‘what’ is diagnosed, it’s the treatment options chosen. Allopathic medicine has two major options, drugs and surgery. If the AMA was less defensive about other modalities, wider options for care could be explored: diet, psychological health, herbs, homeopathics, supplements….and probably more. And someone might consider that our stressful lifestyles, which is a feature of our culture, could use some examination.
Thanks.