By Michelle Andrews
Provided by Kaiser Health News
More From This Series Insuring Your Health
In a new book, Overdiagnosed: Making People Sick in the Pursuit of Health, Dartmouth researchers and physicians H. Gilbert Welch, Lisa Schwartz and Steven Woloshin argue that the medical establishment’s embrace of early diagnosis and treatment as the key to keeping people healthy actually does the opposite.
When doctors order screenings or tests for people who have no symptoms, then diagnose them with illnesses, that’s often overdiagnosis, these authors maintain. Since many of the patients will never develop symptoms, much less get sick or die from these ailments, it leads to costly, unnecessary medical interventions and promotes a culture of sickness rather than health. I spoke with Welch, a professor at Dartmouth’s Institute for Health Policy and Clinical Practice, about what health care might look like if more people adopted their approach.
Q. Prevention is at the heart of the health reform law. New health plans are now required to cover for free all measures recommended by the U.S. Preventive Services Task Force, a group of medical experts that evaluates the effectiveness of preventive services. Their recommendations include screenings for osteoporosis, breast and colon cancer. Is this the right way to prevent disease and save the system money?
A. I’m a supporter of health care reform. The country needs it. Do I have trouble with the emphasis on screening and annual check-ups? Sure. I don’t think people fully understand the ramifications of early detection and that’s why I’m raising questions about it in this book.
There’s the idea that this kind of prevention — identifying medical problems in healthy people — will save money and improve people’s health. It certainly won’t save money. The reason is that early detection identifies so many new patients. Any savings from avoiding the cost of a few patients with advanced disease quickly evaporate in the face of the new cost of intervening early on millions of additional patients.
Q. But will it improve health?
A. It may improve health for some, but it also harms the health of others. The reason is overdiagnosis: the detection of abnormalities in people who are never destined to develop symptoms — or die — from their condition. We don’t know who these patients are, so we treat everybody. That means we are treating some people who can’t benefit from treatment — because there’s nothing to fix. But they can be harmed. The truth is it’s hard to make a well person better, but it’s not hard to make them worse.
Q. Let’s talk about a specific example. You discuss breast cancer screening in your book.
A. Whether a woman should get a mammogram is a personal decision because it’s an incredibly close call. I believe mammography does help some women avoid a breast cancer death, but it’s rare. Our best guess is that you have to screen 2,500 50-year-old women for 10 years in order to help one avoid a breast cancer death.
To be fair to patients, I believe we need to be clear about what happens to the other 2,499. Nearly half will have an abnormal mammogram over that period and have to worry about cancer needlessly. Half of them will have to go on to have a biopsy. And somewhere between 5 and 15 will be overdiagnosed and receive surgery, radiation and/or chemotherapy for a cancer that was never going to bother them.
No one can say what is the “right” thing to do. It’s a personal choice.
Q. Many health care experts today say it’s important that everyone have a “medical home“: a primary care physician who’s their regular go-to person for routine and preventive care, and who coordinates their care with specialists and other health care providers when necessary. If you’re healthy, do you need a medical home?
A. The patients that most need a medical home are those with multiple chronic conditions and who are on many medications.
For people who are well, the virtue of having a regular primary care physician is to establish a relationship and to establish the set of values that will guide your care. You can talk about where you are on the spectrum between aggressively looking for early signs of disease and waiting until you have symptoms to seek out treatment. The first may have the potential benefit of early diagnosis, but the potential harm of being diagnosed and treated for problems that will never become relevant.
Q. Wellness programs for employees used to be pretty limited, offering discounted gym memberships perhaps, but not much else. Now they’re moving into a new realm, with financial incentives for not smoking, and keeping blood pressure, cholesterol and BMI within recommended levels, for example. Is this a good move?
A. It depends. I have no problem with promoting general principles of good health: Eat right, exercise, don’t smoke. Encouraging someone to watch their weight, without being too rigorous or obsessive about it, is reasonable. And people ought to know their blood pressure and cholesterol levels, and get treated if they’re truly at high risk for problems.
But I do worry about two things. First, I believe the recommended thresholds for treating blood pressure, cholesterol and blood sugar have fallen too low. At those levels, the risk that treatment will cause an adverse event — like fainting, in the case of blood pressure medication — is too high. Wellness programs have to be careful not to become part of the problem.
Second, I get a little nervous about tying financial incentives to wellness goals. I don’t want to punish sick people — particularly since they tend to be the most economically vulnerable.
Q. What’s on your wellness wish list?
A. Let’s help people learn how to ask good questions of their doctors. How to understand risk and health statistics so they can make better decisions. Wellness programs could educate and inform people about how to be a critical consumer of health care. Wouldn’t that be something?
Q. You haven’t had a routine physical since you were a child, and it’s not recommended by the U.S. Preventive Services Task Force. Yet many health plans cover an annual physical and health care providers encourage it. Is it a waste of time?
A. If the annual physical is really what it says it is — a comprehensive physical exam to look for something that’s wrong with you — it’s a total waste of time. If it’s an effort to connect with a physician and talk about the way things are going, without looking for lumps and bumps, then having that annual visit may be a good thing.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
What does he mean about wellness programs becoming part of the problem of blood pressure, cholesterol, and blood sugar falling too low? I don’t understand how a wellness program could be part of the problem.
This has been a point of contention within health reform. As usual, it is simply not a cut and paste issue. I was recently with a patient that had a mammogram done because of a lump in her breast. She was told after the study that it was very likely benign. This however, did not comfort her and she elected to have a biopsy. Even though this procedure was not really necessary from a empirical view, it would likely give her comfort and stop the sleepless nights she was having. So even though it was not needed, SHE needed it for her own sanity.
Also, if we want to cut back on the number of imaging studies ordered, we need to have more malpractice protection for physicians as well as educate the public on medical statistics and probability. The reason some studies are ordered is to save one’s ass from being sued if the problem turns out to be worse than initially expected. This does happen in medicine. Especially screening for some cancers.
It seems the Dartmouth docs (like our president) are blaming physicians for the decline in health care and the need for reform. But what about personal accountability? Do you have to sue the doc that followed Dartmouth doc’s advice and didn’t order the image study because it was likely benign only to find out in 6 months that it was cancer?
Educating the public is important but stats is not the only thing they need to know. The public needs to have a better understanding of the inexact science of medicine. The American public expects quick, cheap, and perfect healthcare from our physicians; if we can’t have it we sue. This does not work for anybody.
Robert Kaplan (I think I’m thinking of the right person) has a fair bit of literature published analyzing the variation in patient outcomes (QALY and mortality) following changes in prostate cancer screening guidelines. There are several points that can be made based on his results.
When PSA screening was increased (either by promotion of screening or by decreasing the recommended age for screening) the detected rate of prostate cancer increased tremendously, while mortality rates remained fairly constant. You could potentially explain this by advances in modern medicine, but when screening decreased, later in time, mortality again remained constant. Some ridiculous percentage of cadavers screened (70ish percent iirc) show evidence of prostate cancer by a certain age (I want to say 60+), but prostate cancer was only the cause of death in a small fraction of these cases.
People have to die of something, and there’s a lot of things standing in line to do it. When you increase screening, which in and of itself can have some level of risk without even getting into cost efficacy, positive tests are often linked with some form of treatment, e.g. radiation, surgery, etc., which themselves can cause incontinence, impotence, etc. severely reducing the quality of life of someone who very well may never have died or even suffered ill effects from what was treated. I think Kaplan’s final analysis was that early PSA screening actually reduced QALY’s, so reimbursing that was actually serving to finance a harmful health practice, by the masses.
“What does he mean about wellness programs becoming part of the problem of blood pressure, cholesterol, and blood sugar falling too low? I don’t understand how a wellness program could be part of the problem.”
Similar deal with prostate cancer. There’s no obvious symptoms associated with moderately high blood pressure, and there’s no threshold at which blood pressure, by nature, becomes “disease.” It’s a spectrum, and the lower the level for pathology is set, the lower the bar for treatment as well. Antihypertensives come with their own set of risks, and violating a wellness program’s guidelines would come with its own set of negative repercussions.
It is an interesting thought, that over-screening patients who present with a lack of, or absence of symptoms could in fact be counterproductive and ultimately deleterious to health and wellbeing.
Having completed my undergraduate degree in Health Promotion, preventative medicine is drilled into our minds pretty hard. We are trained to advocate for early detection, and early treatment wherever possible. But the fact is that there is much more to preventative care than screening for, and early treatment of illness.
I think the last point in the Q and A portion of this article is a dangerous one to make. Sure, if an annual physical with a PCP consists solely of health screening and checking for “lumps and bumps” it’s probably not valuable. But ideally, shouldn’t a primary care physician, or a member of their staff, be having a conversation with the patient at the same time, evaluating overall wellness and assessing their risk factors for future disease? I would like to think that a good FM or IM doc has discussions with patients about nutrition, exercise, lifestyle choices etc; that way barriers to the maintenance of good health can be identified and addressed. A checkup shouldn’t be 100% physical exam, and 0% behavioral exam should it?
Interesting article. I didn’t realize that in some instances, early screenings potentially create more harm than good. For patients who undergo early screenings resulting in positive tests, I’d be interested in seeing the extent that physicians educate them about the risks vs. benefits of early treatment. I wonder if treatment is just being “given” with minimal discussion.
One thing that I do think is important, however, is that this idea of “early screenings potentially creating harm” be analyzed in different medical circumstances. As “love of organic” pointed out, maybe early prostate screenings may not result in the best outcomes for the majority of patients. Nevertheless, I see early screening for glaucoma patients (visual field testing, tonometry, checking cup:disc ratio’s, etc) as vital, and I would argue that we need more of it, especially in african american, hypertensive, and diabetic populations, and those with a family history of the disease. Of course..maybe I should research the negative effects of intraocular pressure lowering drugs and other treatments before I go any further… But nevertheless, patient’s being properly informed about the risks vs. benefits of treatment vs nontreatment after the early screening tests come back positive is vital
“I don’t want to punish sick people — particularly since they tend to be the most economically vulnerable.”
If you keep holding their hand, they’ll keep up the bad practices that required you to start holding their hand. Ugh.