A complex web of factors has created the phenomenon of overdiagnosis: the popular media promotes fear of disease and perpetuates the myth that early, aggressive treatment is always best; in an attempt to avoid lawsuits, doctors have begun to leave no test undone, no abnormality overlooked; and profits are being made from screenings, medical procedures, and pharmaceuticals. Revealing the social, medical, and economic ramifications of a health-care system that overdiagnoses and overtreats patients, Dr. H. Gilbert Welch makes a reasoned call for change that would save us pain, worry, and money.
“One of the big strengths of this relatively small book is that if you are inclined to ponder medicine’s larger questions, you get to tour them all. What is health, really?... In the finite endeavor that is life, when is it permissible to stop preventing things? And if the big questions just make you itchy, you can concentrate on the numbers instead: The authors explain most of the important statistical concepts behind evidence-based medicine in about as friendly a way as you are likely to find.”—Abigail Zuger, MD, The New York Times
“One of the most important books about health care in the last several years.”—Cato Institute
“Everyone should read this book before going to the doctor! Welcome evidence that more testing and treatment is not always better!”—Susan Love, MD, author of Dr. Susan Love’s Breast Book
“Very insightful and engaging.”—Dennis Rosen, The Boston Globe
“This brilliantly researched, well-argued, and clearly written book will help us avoid the unnecessary tests, drugs, surgeries, and anxiety that are the inevitable outcome of our epidemic of overdiagnosis.”—Sidney Wolfe, MD, author of Worst Pills, Best Pills and editor of WorstPills.org
My first car was a v´65 Ford Fairlane wagon. It was a fairly simple--albeit large--vehicle. I could even do some of the work on it myself. There was a lot of room under the hood and few electronics. The only engine sensors were a temperature gauge and an oil-pressure gauge.
Things are very different with my v´99 Volvo. There’s no extra room under the hood--and there are lots of electronics. And then there are all those little warning lights sensing so many different aspects of my car’s function that they have to be connected to an internal computer to determine what’s wrong. Cars have undoubtedly improved over my lifetime. They are safer, more comfortable, and more reliable. The engineering is better. But I’m not sure these improvements have much to do with all those little warning lights. Check-engine lights--red flags that indicate something may be wrong with the vehicle--are getting pretty sophisticated. These sensors can identify abnormalities long before the vehicle’s performance is affected. They are making early diagnoses.
Maybe your check-engine lights have been very useful. Maybe one of them led you to do something important (like add oil) that prevented a much bigger problem later on.
Or maybe you have had the opposite experience.
Check-engine lights can also create problems. Sometimes they are false alarms (whenever I drive over a big bump, one goes off warning me that something’s wrong with my coolant system). Often the lights are in response to a real abnormality, but not one that is especially important (my favorite is the sensor that lights up when it recognizes that another sensor is not sensing). Recently, my mechanic confided to me that many of the lights should probably be ignored.
Maybe you have decided to ignore these sensors yourself. Or maybe you’ve taken your car in for service and the mechanic has simply reset them and told you to wait and see if they come on again.
Or maybe you have had the unfortunate experience of paying for an unnecessary repair, or a series of unnecessary repairs. And maybe you have been one of the unfortunate few whose cars were worse off for the efforts.
If so, you already have some feel for the problem of overdiagnosis.
I don’t know what the net effect of all these lights has been. Maybe they have done more good than harm. Maybe they have done more harm than good. But I do know there’s little doubt about their effect on the automotive repair business: they have led to a lot of extra visits to the shop.
And I know that if we doctors look at you hard enough, chances are we’ll find out that one of your check-engine lights is on.
A routine checkup
I probably have a few check-engine lights on myself. I’m a male in my midfifties. I have not seen a doctor for a routine checkup since I was a child. I’m not bragging, and I’m not suggesting that this is a path others should follow. But because I have been blessed with excellent health, it’s kind of hard to argue that I have missed out on some indispensable service.
Of course, as a doctor, I see doctors every day. Many of them are my friends (or at least they were before they learned about this book). And I can imagine some of the diagnoses I could accumulate if I were a patient in any of their clinics (or in my own, for that matter):
? From time to time my blood pressure runs a little high. This is particularly true when I measure it at work (where blood pressure machines are readily available). Diagnosis: borderline hypertension
? I’m six foot four and weigh 205 pounds; my body mass index (BMI) is 25. (A “normal” BMI ranges from 20 to 24.9.) Diagnosis: overweight
? Occasionally, I’ll get an intense burning sensation in my midchest after eating or drinking. (Apple juice and apple cider are particularly problematic for me.) Diagnosis: gastroesophageal reflux disease
? I often wake up once a night and need to go to the bathroom. Diagnosis: benign prostatic hyperplasia
? I wake up in the morning with stiff joints and it takes me a while to loosen up. Diagnosis: degenerative joint disease
? My hands get cold. Really cold. It’s a big problem when I’m skiing or snowshoeing, but it also happens in the office (just ask my patients). Coffee makes it worse; alcohol makes it better. Diagnosis: Raynaud’s disease
? I have to make lists to remember things I need to do. I often forget people’s names--particularly my students’. I have to write down all my PINs and passwords (if anyone needs them, they are on my computer). Diagnosis: early cognitive impairment
? In my house, mugs belong on one shelf, glasses on another. My wife doesn’t understand this, so I have to repair the situation whenever she unloads the dishwasher. (My daughter doesn’t empty the dishwasher, but that’s a different topic.) I have separate containers for my work socks, running socks, and winter socks, all of which must be paired before they are put away. (There are considerably more examples like this that you don’t want to know about.) Diagnosis: obsessive-compulsive disorder
Okay. I admit I’ve taken a little literary license here. I don’t think anyone would have given me the psychiatric diagnoses (at least, not anyone outside of my immediate family). But the first few diagnoses are possible to make based solely on a careful interview and some simple measurements (for example, height, weight, and blood pressure).
Table of Contents...
Introduction: Our Enthusiasm for Diagnosis
Chapter 1) Genesis: People Become Patients with High Blood Pressure
Chapter 2) We Change the Rules: How Numbers Get Changed to Give You Diabetes, High Cholesterol, and Osteoporosis
Chapter 3) We Are Able to See More: How Scans Give You Gallstones, Damaged Knee Cartilage, Bulging Discs, Abdominal Aortic Aneurysms, and Blood Clots
Chapter 4) We Look Harder for Prostate Cancer: How Screening Made It Clear That Overdiagnosis Exists in Cancer
Chapter 5) We Look Harder for Other Cancers
Chapter 6) We Look Harder for Breast Cancer
Chapter 7) We Stumble onto Incidentalomas That Might Be Cancer
Chapter 8) We Look Harder for Everything Else: How Screening Gives You (and Your Baby) Another Set of Problems
Chapter 9) We Confuse DNA with Disease: How Genetic Testing Will Give You Almost Anything
Chapter 10) Get the Facts
Chapter 11) Get the System
Chapter 12) Get the Big Picture
Conclusion: Pursuing Health with Less Diagnosis
- Click here to read an article regarding whether patients want more or less treatment posted on the New York Times "Well" blog
- Click here to read an article featuring Dr. Welch in Scientific American
- Click here to read an article featuring Dr. Welch in the New York Times
- Click here to read an article featuring Dr. Welch's recent study on mammogram testing in the New York Times
- Click here to read a New York Times editorial featuring Dr. Welch's analysis on the long term success of mammography screening
- Click here to read an article featuring Dr. Welch's work in the Huffington Post
- Click here to read an article featuring Dr. Welch's work in New York Times Magazine
- Click here to read a review of Dr. Welch's work in Health Affairs
- Click here to read an article featuring Dr. Welch's work in Time magazine
- Click here to read an interview with Dr. Welch on People's Pharmacy
- Click here to read an op-ed by Dr. Welch's in the Los Angeles Times
- Click here to read a review of Dr. Welch's work in the Lancet
- Click here to read an article featuring Dr. Welch's work on Top News
- Click here to read an article featuring Dr. Welch's work on Fox43 News
- Click here to read an article featuring Dr. Welch's work in the Los Angeles Times
- Dr. H. Gilbert Welch on Ageless Life with Dr. Michael Brickey; click here to listen
- Dr. H. Gilbert Welch on CBC Radio, April 9th, 2011; click here to listen
- Overdiagnosed featured here in The New York Times
- Dr. H. Gilbert Welch on NPR's Science Friday, February 11th, 2011; click here to listen
- Read an interview with Dr. Welch in the The Los Angeles Times
- Read an interview with Dr. Welch in the Boston Globe
- Read an interview with Dr. Welch in the Washington Post
- Read opinion piece by author on CNN.com
- Read an interview with Welch on the Wall Street Journal Health Blog
- Click hereto read an pp-ed piece by Dr. Welch in the New York Times Aug 20, titled "Testing What We Think We Know"
- Click here to read a write-up in The Archives of Internal Medicine
- Click here to read a write-up in The New England Journal of Medicine
- Click here to read an article about Dr. Welch on NPR.org
- Click here to read an article, "Is Breast Cancer Overdiagnosed?" in The Pittsburgh Post-Gazette
- Click here to read a report featuring Dr. Welch on CBS News
- Click here to read an article about Dr. Welch in Valley News
- Click here to read an article mentioning Dr. Welch in The Boston Globe's Daily Dose
- Click here to read an article about Dr. Welch's study, "1.3 million overdiagnosed for breast cancer in US" in NY Daily News
- Read "More Depth: Phenotype, genotype and blood clots" (from chapter 9, footnote 2)
- Welch is quoted in this New York Times article about doubting the value of mammograms, 2/11/14
- New York Times op-ed by Welch, "Breast Cancer Screenings: What We Still Don't Know," 12/29/13
- Dr. H. Gilbert Welch on the Thom Hartmann Program, February 16th, 2011; click here to listen.
- Click here to watch an author appearance on PBS's P "Money & Medicine"