Making People Sick
In the Pursuit of Health
H. Gilbert Welch, M.D. et al
Sean Runnette, Reader
Hypertension is defined by a numerical rule. If your blood pressure is above a certain number, you have hypertension. If it isn't above that number, you don't. But hypertension isn't the only condition defined by a numerical rule. There are many conditions that you can be labeled with simply because you are on the wrong side of a number, not because you have any symptoms.
Diabetes is defined by a number for blood sugar; hyperlipidemia is defined by a number for cholesterol; and osteoporosis is defined by a number for bone density (called a T score). Of course, in each of these conditions doctors are trying to get ahead of symptoms - - - we are trying to make diagnoses early in order to prevent bad events such as leg amputation and blindness from diabetes, heart attacks and strokes from high cholesterol, and wrist and hip fractures from osteoporosis.
But whenever we make diagnoses ahead of symptoms, overdiagnosis becomes a problem. Some people diagnosed with diabetes, high cholesterol, and osteoporosis will never develop symptoms or die from the conditions. And this is most likely the case for those in whom the condition is mild.
The numerical rules used to define conditions are really important. They typically involve a single number: if you fall on one side of the number you are defined as well; if you're on the other, you are defined as abnormal. These numbers - - - called cutoffs or thresholds - - - determine who has a condition and who doesn't. They determine who gets treatment and who doesn't. And they determine how much overdiagnosis occurs.- - - OverdiagnosedMRI, CAT scan, PET scan, DXA, Ultrasound. All great, no? Catch that disease or sickness before it takes you over, right?
Well - - - yes and no. Vivekanda said you can't know everything, but Welch claims that we can certainly know too much about what is going on in the body. For instance, finding polyps that may have remained hidden for the rest of your life if it weren't for the new high resolution capacity of scans. Which may mean encountering cancers that are not large, and - - - even more importantly - - - are not even growing; ones that may turn out to be, paradoxically, neither benign nor harmful for you.
Overdiagnosed is a careful overview of what is happening in the new high-tech modern medicine that forces many of us to go from being people to being patients. You may have no pain, no symptoms of gallstones, damaged knee cartilage or bulging discs in your back . . . but a scan may hint that something is wrong with you. And your doctor is required to tell you if there are "abnormalities" - - - and in some cases, may recommend procedures which will cost you time, money (even if you are insured), anxiety - - - serious anxiety - - - and procedures, all invasive, sometimes dangerously so.
The rule of thumb is that once found, we must do something about it. But the reality in many cases arises from that old saw: if it ain't broke, don't fix it.
"Abnormalities." In med-talk that means that they see something not normal. Yet in what is now called the Framingham Heart Study, a scan of the upper parts of 2,000 people with no previous "clinical diagnosis of stroke" found that "over 10 percent of these healthy participants had had strokes sometime in their lives." These are called "silent strokes:" they came, they went - - - and no one (least of all, the volunteers in this study) were the wiser.
The chance of stroke increases with age, but the surprise was that in the FHS, "7 percent under age of fifty had evidence of having had a stroke."
"The reservoir of abnormalities in the general population goes well beyond gallstones, musculoskeletal findings, and strokes" Welch explains. "One radiologist who had scanned more than ten thousand people noted that"
the realities are, with this level of information, I have yet to see a normal patient.In a recent study of over a thousand people who elected to undergo a total-body CT screening - - - people with no symptoms - - - 86 percent had at least one abnormality detected.
Because there were so many abnormalities, the researches calculated that the average individual had 2.8 abnormalities.
At this very moment, you and I are carrying around within us something - - - a cancer, a polyp, a lump, a swelling, an anomaly somewhere in our bodies that has not been previously detected, and - - - if we are lucky - - - will never be detected until we are safely bedded down in our graves.
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Welch tells us that "A lot of messages about health screening are simply variations on the same theme; in one form or another, they all push the idea that the best way to stay healthy is to look hard for things that might be wrong." These messages reflect the best of intentions. But there is a kicker. Sometimes, health-care companies, hospitals, and some doctors advise people to be screened because they are in the business of selling the service. Doctors, we find, are themselves not immune to overdiagnosis.
One of Welch's colleagues practiced internal medicine. When he went for a PSA test - - - the standard test for cancer of the prostate - - - it came out positive (remember, positive is that strange counterintuitive word in medbiz for "bad" "you should be prepared for the worst." And when you are given a clean bill of health, the other counterinuititive word is "negative.")
Welch's friend elected surgery to completely remove his prostate. Bad move. He had obviously not read The Invasion of the Prostate Snatchers, a recent succinct volume on all the reasons for us to avoid a prostatectomy:
The prostate is located within millimeters of the urinary bladder and the rectum, so there is zero tolerance for a slip of the scalpel. To make matters worse, there is a prolific venous blood supply surrounding the gland. Even the best surgeons can end up operating in a pool of blood, without a clear view of the object they are trying delicately to remove . . . The greatest danger from pooling blood in the operative field is the surgeon's restricted ability to see clearly in order to spare the minuscule nerves that control erections --- nerves thinner than a human hair and invisible to the unaided eye.
Welch's friend felt that he had no choice; as a M. D. he wanted not to be "tainted" by the knowledge that he was cancerous. However, cancer of the prostate is one of the slowest moving cancers - - - experts often suggest that men, after a certain age, would be wise to avoid a prostatectomy.
The result of the doctor's operation: general malaise and lack of energy for months, coupled with permanent - - - for the rest of his life - - - sexual dysfunction. Again, if it ain't broke don't fix it.
This book is jammed with facts and figures and mathematical odds and tables, and the message is very clear. After a medical exam - - - especially with one that involves one of these new up-to-date scans (I almost wrote "scams"), if you are diagnosed with something ghastly, don't blow it by taking immediate action. Make yourself a good researcher and go for "the facts."
For the figures for possible fatality or real live danger can be manipulated. Look for the odds, research that has come from a "blind study," one that involves a control group, one, preferably, not done with funding of a drug company.
Don't depend on one specialist for information. Spend time with Google, and look for books like The Invasion of the Prostate Snatchers and Overdiagnosed. You have everything to lose and nothing to gain by looking askcance at one suggestion by one doctor who may have other irons in the fire, ones that indeed may come back to burn you if you are not careful.
This book came out several years ago, this HighBidge audio version sound edition with Sean Runnette arrived more recently.
The book itself may make you rock and reel in a sea of type. What with all its facts, figures, charts and diagrams, I think you are better off with the sound edition. The facts and charts and tables may not be all that memorable - - - but the underlying message will come through. Loud and clear.