[Infowarrior] - What ¹ s Making Us Sick Is an Epidemic of Diagnoses

[Richard Forno]

January 2, 2007
Essay
What¹s Making Us Sick Is an Epidemic of Diagnoses
By H. GILBERT WELCH, LISA SCHWARTZ and STEVEN WOLOSHIN
http://www.nytimes.com/2007/01/02/health/02essa.html?_r=2&oref=slogin&pagewa
nted=print

For most Americans, the biggest health threat is not avian flu, West Nile or
mad cow disease. It¹s our health-care system.

You might think this is because doctors make mistakes (we do make mistakes).
But you can¹t be a victim of medical error if you are not in the system. The
larger threat posed by American medicine is that more and more of us are
being drawn into the system not because of an epidemic of disease, but
because of an epidemic of diagnoses.

Americans live longer than ever, yet more of us are told we are sick.

How can this be? One reason is that we devote more resources to medical care
than any other country. Some of this investment is productive, curing
disease and alleviating suffering. But it also leads to more diagnoses, a
trend that has become an epidemic.

This epidemic is a threat to your health. It has two distinct sources. One
is the medicalization of everyday life. Most of us experience physical or
emotional sensations we don¹t like, and in the past, this was considered a
part of life. Increasingly, however, such sensations are considered symptoms
of disease. Everyday experiences like insomnia, sadness, twitchy legs and
impaired sex drive now become diagnoses: sleep disorder, depression,
restless leg syndrome and sexual dysfunction.

Perhaps most worrisome is the medicalization of childhood. If children cough
after exercising, they have asthma; if they have trouble reading, they are
dyslexic; if they are unhappy, they are depressed; and if they alternate
between unhappiness and liveliness, they have bipolar disorder. While these
diagnoses may benefit the few with severe symptoms, one has to wonder about
the effect on the many whose symptoms are mild, intermittent or transient.

The other source is the drive to find disease early. While diagnoses used to
be reserved for serious illness, we now diagnose illness in people who have
no symptoms at all, those with so-called predisease or those ³at risk.²

Two developments accelerate this process. First, advanced technology allows
doctors to look really hard for things to be wrong. We can detect trace
molecules in the blood. We can direct fiber-optic devices into every
orifice. And CT scans, ultrasounds, M.R.I. and PET scans let doctors define
subtle structural defects deep inside the body. These technologies make it
possible to give a diagnosis to just about everybody: arthritis in people
without joint pain, stomach damage in people without heartburn and prostate
cancer in over a million people who, but for testing, would have lived as
long without being a cancer patient.

Second, the rules are changing. Expert panels constantly expand what
constitutes disease: thresholds for diagnosing diabetes, hypertension,
osteoporosis and obesity have all fallen in the last few years. The
criterion for normal cholesterol has dropped multiple times. With these
changes, disease can now be diagnosed in more than half the population.

Most of us assume that all this additional diagnosis can only be beneficial.
And some of it is. But at the extreme, the logic of early detection is
absurd. If more than half of us are sick, what does it mean to be normal?
Many more of us harbor ³pre-disease² than will ever get disease, and all of
us are ³at risk.² The medicalization of everyday life is no less
problematic. Exactly what are we doing to our children when 40 percent of
summer campers are on one or more chronic prescription medications?

No one should take the process of making people into patients lightly. There
are real drawbacks. Simply labeling people as diseased can make them feel
anxious and vulnerable ‹ a particular concern in children.

But the real problem with the epidemic of diagnoses is that it leads to an
epidemic of treatments. Not all treatments have important benefits, but
almost all can have harms. Sometimes the harms are known, but often the
harms of new therapies take years to emerge ‹ after many have been exposed.
For the severely ill, these harms generally pale relative to the potential
benefits. But for those experiencing mild symptoms, the harms become much
more relevant. And for the many labeled as having predisease or as being ³at
risk² but destined to remain healthy, treatment can only cause harm.

The epidemic of diagnoses has many causes. More diagnoses mean more money
for drug manufacturers, hospitals, physicians and disease advocacy groups.
Researchers, and even the disease-based organization of the National
Institutes of Health, secure their stature (and financing) by promoting the
detection of ³their² disease. Medico-legal concerns also drive the epidemic.
While failing to make a diagnosis can result in lawsuits, there are no
corresponding penalties for overdiagnosis. Thus, the path of least
resistance for clinicians is to diagnose liberally ‹ even when we wonder if
doing so really helps our patients.

As more of us are being told we are sick, fewer of us are being told we are
well. People need to think hard about the benefits and risks of increased
diagnosis: the fundamental question they face is whether or not to become a
patient. And doctors need to remember the value of reassuring people that
they are not sick. Perhaps someone should start monitoring a new health
metric: the proportion of the population not requiring medical care. And the
National Institutes of Health could propose a new goal for medical
researchers: reduce the need for medical services, not increase it.

Dr. Welch is the author of ³Should I Be Tested for Cancer? Maybe Not and
Here¹s Why² (University of California Press). Dr. Schwartz and Dr. Woloshin
are senior research associates at the VA Outcomes Group in White River
Junction, Vt.