Protecting Yourself From Overdiagnosis

Bill, a healthy looking guy in his mid-40s, came to WholeHealth Chicago because he wanted to get off Lipitor, the widely prescribed cholesterol-lowering drug. Bill had virtually no risks for heart disease and all four of his grandparents were still alive and quite independent, but a few years ago his cholesterol was on the high side and his doctor insisted on the Lipitor.

Arthur has been taking a beta blocker for high blood pressure for ten years. Over that decade he became a self-described health nut, marathon runner, and Whole Foods habitué. Arthur’s now the whole enchilada of good health, but his doctor still wants him on his med.

Tammi, in her late 20s, has been struggling with her thyroid hormone replacement medication. In her teens, complaining of a sensation of fullness in her neck, she had some thyroid testing and even though she felt fine was told she had an overactive thyroid and was given radioactive iodine, which wiped out her thyroid function altogether. She hasn’t felt well since.

Robert, now 30, had been taking Seroquel, a med for bipolar disorder, since college. “I sort of acted out a lot. The psychiatrist said I was bipolar and since then everyone has been afraid to stop my med.”

Marisol has been taking Plaquenil and low-dose prednisone for years after a screening test for the autoimmune disease lupus revealed a positive ANA (antinuclear antibody) result. She was told she had lupus and could die without meds.

Danielle has been popping Nexium (for heartburn) for as long as she can remember. Bob is scheduled for an arthroscopy because of his knee pain, Jack to have his prostate biopsied and probably  removed. Mary’s anxious about the upcoming biopsy of a tiny abnormality on her mammogram. Linda has read about her upcoming LEEP procedure (removing abnormal cells from her cervix) and wonders if there are  alternatives.

Believe me, the list could go on. What I’ve just described are some of America’s most overdiagnosed and overtreated conditions.

Overdiagnosis
The concept of overdiagnosis–labeling patients with conditions that probably aren’t particularly dangerous and initiating treatment that may be either unnecessary or do more harm than good–has become a major issue. European physicians actually convene annually to discuss strategies to reverse this worrisome trend. A real expert on the subject is H. Gilbert Welch, MD, an internist and professor at Dartmouth Medical School, who has written two books Overdiagnosed and Less Medicine, More Health.

How do we get labeled with conditions that might not be “conditions” at all? Tammi and her thyroid, Danielle with her Nexium, and Jack’s soon-to-vanish prostate can be reduced to the same few factors:

Screening tests  Having regular checkups and being screened for frightening conditions like cancers of the breast and prostate, getting your blood pressure taken, and knowing your cholesterol levels all sound like sensible preventive measures. The problem is deciding what’s worth treating and what’s not. If you have consistently high blood pressure, it does need to be treated. Unfortunately, many patients have been taking unnecessary blood pressure drugs despite telling their doctors “But it’s only high in your office!” Tens of thousands of men had their prostate glands removed before someone did the math and found that this group’s death rates from prostate cancer were the same as men who never had prostate screening at all. Countless breast surgeries have been performed on women whose mammograms were “suspicious.”

Shoddy standards for deciding what constitutes “disease”  Psychiatry takes a lot of justifiable heat for this, and all physicians (including psychiatrists) complain that the insurance industry requires them to place a diagnosis on the insurance claim form in order to get paid. The American Psychiatric Association’s DSM (Diagnostic and Statistical Manual of Mental Disorders, a standardized classification of mental disorders) makes labeling patients with bipolar disorder, ADD, or schizophrenia all too easy. Once labeled, meds follow. And once labeled, it’s easier to get a tattoo removed from your forehead than to get a diagnosis expunged from your records.

Marisol’s positive test result for ANA with absolutely no other evidence of lupus is, after 30 years, finally being appreciated as a “false positive, no treatment needed.” Danielle could start some lifestyle changes for her GERD and when she feels it coming on simply mix a half teaspoon of baking soda in a little water rather than take 3,650 Nexiums (Nexia?) over the next decade.

Big Pharma wants you diagnosed so you’ll buy their product. You’re assaulted with drug ads to convince you you’re ill when you’re actually not. This can lead to setting health goals (“Lower your HbA1c!”) that are controversial. We physicians are flooded with questionable medical studies that, when explored in depth, have led to “diseases” whose treatment will likely not add a single minute to our patients’ lives. For example, the standards that allegedly established the point at which blood pressure was high enough to initiate treatment or cholesterol high enough to start a statin can be traced to industry-funded medical gatherings. 

The for-profit health care system  Even though knee arthroscopies have been shown to have no long-term benefit and to not be any better at relieving symptoms than sham arthroscopy (incision only, no arthroscopy), orthopedic surgeons still perform 700,000 a year. Despite knowing there was no drop in the number of deaths from prostate cancer with intensive PSA screening and aggressive surgical intervention, urologists performed 150,000 prostatectomies last year. When a screening test picks up early osteoporosis, you catch a double whammy. Big Pharma charges $1,200 for a single IV infusion of Reclast and the sky’s the limit for the hospital IV charge. Fees ranging from $500 to $15,000 (!) have been reported by patients. Until I tossed them, I had stacks of Big Pharma’s osteoporosis screening guides around the office. I remember a drug rep once asking “Can you give me a reason why you wouldn’t screen every woman over 40 in your practice for osteoporosis?”

So what to do about this unsavory state of  affairs?
How can you protect yourself from unnecessary medications and surgical procedures? Here’s a primer:

–Cultivate skepticism into an art form to the point where you suspend belief in the healthcare system. We use the words “suspend disbelief” to enjoy anything theatrical. We know in our hearts that King Kong didn’t really climb the Empire State Building, but by suspending disbelief we enjoy the movie. Now you’ve got to suspend your belief in a system that may not have your best interests in mind.

–Think carefully about screening tests. Virtually all doctors agree that annual check­ups aren’t needed for healthy adults. You’re offered them by your health insurance company because they’re inexpensive and they keep you from complaining about the otherwise shoddy coverage they sell you. The folks at the popular Life Line Screening never say the words “not necessary” and will happily screen you for conditions you’ll likely never have. Keep up with the latest guidelines on mammograms and Pap smears. If recommendations conflict with each other (first mammogram at 40 or 50), choose the one that asks you to do less rather than more.

–Question medical authorities relentlessly. Practice these sentences: “Do I really need to do this?” and “Do I really need to take this?” and “What are my other options?” Get second and even third  opinions.

–If you use the internet to keep yourself informed (a positive, in my view), check the publication date of what you’re reading. Medical flip-flopping is common. A must-have treatment in 2003 may be completely reversed in 2019. The gushing praise for PSA screening ten years ago has pretty much vanished.

And, of course, the very best way to avoid overdiagnosis is to keep yourself so healthy you don’t really need us at all. Here’s an excellent if lengthy 2017 Atlantic article that looks closely at unnecessary and unhelpful medical treatments. I’m quoting this section for obvious reasons, but please click through and read it all.

The health problems that most commonly afflict the American public are largely driven by lifestyle habits—smoking, poor nutrition, and lack of physical activity, among others. In November, a team led by researchers at Massachusetts General Hospital pooled data from tens of thousands of people in four separate health studies from 1987 to 2008. They found that simple, moderate lifestyle changes dramatically reduced the risk of heart disease, the most prolific killer in the country, responsible for one in every four deaths. People deemed at high familial risk of heart disease cut their risk in half if they satisfied three of the following four criteria: didn’t smoke (even if they smoked in the past); weren’t obese (although they could be overweight); exercised once a week; ate more real food and less processed food. Fitting even two of those categories still substantially decreased risk. In August, a report issued by the International Agency for Research on Cancer concluded that obesity is now linked to an extraordinary variety of cancers, from thyroids and ovaries to livers and colons.

Be well,
David Edelberg, MD