One of the "hazards" in our country with its sophisticated healthcare delivery system and well trained physicians is overdiagnosis. This is a logical consequence of broad health insurance coverage, a multitude of physicians (particularly in urban areas), and physician training oriented to the identification of disease. I have previously referred to this latter phenomenon as the disease model (see: Wellness, Preventive Medicine, and the Classic Disease Model; Predisposition to Disease and Pre-Disease on the Health Continuum). It turns out that one physician-author has studied this problem (see: Health Blog Q&A: H. Gilbert Welch, Author of ‘Overdiagnosed’). Below is an excerpt from a blog note about him and his ideas:
At the beginning of his new book, “Overdiagnosed,” Dartmouth professor H. Gilbert Welch imagines all the medical diagnoses he might receive if he were given a thorough physical — borderline hypertension, overweight, benign prostate enlargement, degenerative joint disease and a few others — even though he generally feels pretty good. Welch and co-authors...write about the hazards of looking too hard for conditions or illnesses in healthy people, including additional procedures that carry no benefit but may cause harm, higher health-care costs and the psychological impact of being told you’re sick. We chatted recently with Welch. Here are edited excerpts: Overdiagnosis occurs when physicians make a diagnosis in an individual who would never go on to develop symptoms or die from the condition. It happens when we try to make diagnoses too early, in people who don’t have symptoms. I’m not saying we should never do that, but members of the general public have gotten the message that early diagnosis is always in your best interest, that it’s always good to look harder and find more. But the reality now is that we can find abnormalities in just about everyone and that can start a whole train of harmful events. So we all need to adopt a more balanced approach. Overdiagnosis doesn’t necessarily lead to overtreatment, but it often does.
The blog author asked Dr. Welch what I personally consider a key question in this discussion -- the appropriate patient response to overdiagnosis. I quote it below with his answer:
Q: So when your physician offers you a test, what should you do?:
A: First get a sense of how you feel about this issue. Some people prefer to look as hard as they can for anything that might cause problems in the future with the hope of avoiding those outcomes, understanding that the price they’ll pay for this is a vast increase in being told about things that won’t matter. That may mean unnecessary treatment and side effects. Other people may feel they’re well as long as they feel well and won’t [get screened and tested for everything], accepting the fact that perhaps they’ll miss some benefit of finding something early. See where you sit on this spectrum and communicate with your doctor....When a specific test is being offered or suggested, ask why the physician is recommending it....Ask whether the physician him- or herself has the test. And ask what randomized trials show about how it helps in the long run, how much evidence there is to support that and how many people are overtreated.
Because most physicians are trained to diagnose and treat disease, I suspect that some will find the dialogue described above somewhat silly and irrelevant. I further suspect that most physicians will respond to their patients in the following way: "Let's pursue the possible and relevant diagnoses first. If the results are positive, then we will discuss whether to treat or not treat, taking into consideration the benefits and side-effects of treatment." I think that it would be hard for most patients not to go along with such a plan. Nevertheless, this book opens up a new and important diaglogue that deserves additional discussion. What do all of you think? I believe that overdiagnosis => overtreatment but I am not sure now to change the process.