Smart Bombs: Suffering from overdiagnosis

Our country has the highest medical costs in the world, so the last thing we ought to encourage is treating healthy people. But our system does just that, and the results can be sickening.

That’s the diagnosis of Dr. Gilbert Welch, author of “Overdiagnosed: Making People Sick in the Pursuit of Health.” He also wrote “Should I Be Tested for Cancer? Maybe Not and Here’s Why.” He delivered a jaw-dropping speech at the Riverpoint campus Feb. 21 that – and this is most encouraging – did not provoke a flogging by an audience of health care providers. In fact, he was invited, which indicates a willingness to improve the system.

Welch himself is a practicing physician and professor at Dartmouth Medical School. He did not soft-pedal his message: Our health care system has ensnared too many healthy people by lowering treatment thresholds, and calling for excessive screening.

Welch traces the threshold issue back to the changing of numerical guidelines for hypertension. Normal blood pressure is 120/80, and there was a time when it took a diastolic pressure (the denominator) of 100 before doctors would intervene; now it’s 90. The goal post for systolic pressure (the numerator) was moved from 160 to 140.

Then medical committees lowered the treatment thresholds for cholesterol, diabetes and osteoporosis. Many experts on these panels had financial ties to drug and medical device companies. Overnight, 13 million more people had hypertension, 42 million were pegged with high cholesterol, 1.6 million became diabetics and 6.7 million were diagnosed with osteoporosis. The problem is most of these patients had yet to exhibit any symptoms, and may never have a problem.

Welch said defensive medicine is not the culprit. “You could kill all the lawyers,” he said, and overdiagnosis would still be a problem.

Welch was also critical of wellness programs and scary public health campaigns that drive people who are feeling fine into the offices of folks too willing to discover otherwise. He doesn’t dismiss the marvelous technological breakthroughs that allow physicians to peer into the body and spot heretofore invisible irregularities, but he believes the response to detection creates too many treatable moments.

Autopsy studies show that people die with myriad masses, tumors, cancers and other irregularities that weren’t the cause of death and probably never would’ve been. Prostate and thyroid cancers are fairly common in corpses, Welch said.

So now that doctors can see all of that – if they order enough tests – what are they to do? The answer, he said, is to supply patients with more information on risks vs. rewards and to remain open to the idea of doing nothing.

Unfortunately, warped incentives stand in the way. When Welch worked for Veterans Affairs, he was graded on his ability to shift, say, cholesterol readings in a “healthier” direction, even if the current numbers had yet to produce problems. As a result, more drugs for people who didn’t need them. Some doctors must perform a checklist of tasks before they are reimbursed by an insurer. Welch said the fee-for-service payment system also contributes to overdiagnosis.

Welch didn’t go into detail on the media’s responsibility for overdiagnosis, but it’s fair to say the way health care is covered is part of the problem. We like a heart-rending cancer survivor story, but we need to re-examine survivor rates. As Welch noted, the easiest way for a cancer center to inflate its success is to diagnose more people with cancer. Some who would’ve never died may be called “survivors.”

Ultimately, the solution to overdiagnosis is to remember that healthy people derive no benefit from unneeded health care. But it can make them sick. It might even kill them.

As the physician’s oath says, “First, do no harm.”