Product Code: 4876
ISBN: 9780807021996
Format: Paperback
Publisher: Beacon Press
Published Date: 01/03/2012
Pages: 248
Availability: Not currently available.
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Price: $15.00

Going against the conventional wisdom reinforced by the medical establishment and Big Pharma that more screening is the best preventative medicine, Dr. Gilbert Welch builds a compelling counterargument that what we need are fewer, not more, diagnoses. Documenting the excesses of American medical practice that labels far too many of us as sick, Welch examines the social, ethical, and economic ramifications of a health-care system that unnecessarily diagnoses and treats patients, most of whom will not benefit from treatment, might be harmed by it, and would arguably be better off without screening.

Drawing on twenty-five years of medical practice and research on the effects of medical testing, Welch explains in a straightforward, jargon-free style how the cutoffs for treating a person with "abnormal" test results have been drastically lowered just when technological advances have allowed us to see more and more "abnormalities," many of which will pose fewer health complications than the procedures that ostensibly cure them. Citing studies that show that 10 percent of two thousand healthy people were found to have had silent strokes, and that well over half of men over age sixty have traces of prostate cancer but no impairment, Welch reveals overdiagnosis to be rampant for numerous conditions and diseases, including diabetes, high cholesterol, osteoporosis, gallstones, abdominal aortic aneuryisms, blood clots, as well as skin, prostate, breast, and lung cancers.

With genetic and prenatal screening now common, patients are being diagnosed not with disease but with "pre-disease" or for being at "high risk" of developing disease. Revealing the economic and medical forces that contribute to overdiagnosis, Welch makes a reasoned call for change that would save us from countless unneeded surgeries, excessive worry, and exorbitant costs, all while maintaining a balanced view of both the potential benefits and harms of diagnosis. Drawing on data, clinical studies, and anecdotes from his own practice, Welch builds a solid, accessible case against the belief that more screening always improves health care.

Praise for Overdiagnosed:

"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


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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

Acknowledgments
Notes
Index

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 mid-fifties. 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 mid-chest 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).

"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

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