The problem lies in judgment. The author of the article in the NYT is clearly aware of the “defining deviancy down” of modern medicine. Yet … there are those studies.

The lower your BP, the lower your risk of stroke, heart attack, renal failure. The lower your LDL, the lower your risk of a CV event. The lower your HgbA1C if you are diabetic the lower your risk of nephropathy, neuropathy, retinopathy and vascular disease.

All these things are not based on wishes, but on studies that we are told are conclusive and have been discussed at the very top levels of the medical community and found accurate.

So, the question is, should we be recommending interventions of proven benefit when patients are already on lots of other therapies for other problems, or should we minimize primary prevention for patients with established medical problems?

Someone with RA can take up to 4 meds just to control their joint pain. If they have a high blood pressure and cholesterol (made more likely by steroid treatment) it is likely that that person will benefit MORE from treatment than a similar patient without chronic illness. Now if you consider the person smokes …

It’s all well and good to decry the overdiagnosis and overtreatment. But what specific diseases is the doctor suggesting we stop diagnosing and treating (he seems to think prostate cancer is a good candidate), obviously he’s not aware of the judgment against the doctor who had a patient give informed consent NOT to have the test, was later sued for it and lost because “it’s an easy test to get.”

A couple of things. First, nowhere in the article did I see the problem described as too many diagnoses for a single patient but as the problem of too many people diagnosed. In fact, the article specifically talked about more and more healthy people being labelled as sick and fewer people left who are healthy, not about sick people getting different drugs.

The second thing I’d like to point out is that this risk reduction that Evan mentions in this quote
The lower your BP, the lower your risk of stroke, heart attack, renal failure. The lower your LDL, the lower your risk of a CV event. The lower your HgbA1C if you are diabetic the lower your risk of nephropathy, neuropathy, retinopathy and vascular disease.
is a relative risk reduction which in absolute terms is often so small it can barely be seen under the microscope. Not to mention that the benefit, as Steve Lucas pointed out, is 20 years in the future (which you still need to survive). When the probability of benefit to an individual is tiny and is far away, even the small risk of side effects is important. A tiny probability of a rare serious side effect may not be so much smaller than a small absolute risk reduction, especially considering the number of years a person has to be on these drugs to get any benefit. In addition, more common not serious side effects may interfere with the quality of life for 20 years before any benefit is seen.

When you are treating sick people you are doing your best to make them feel better or save their lives at maybe a small risk of side effects. But you cannot make healthy people feel better now, so you are essentially asking them to take a risk of feeling worse or suffering a rare side effect at present in exchange for a small risk reduction in maybe distant future. Yet this difference is often lost during office visits and more importantly in “guidelines”. Doctors rarely present the information in terms of NNS or absolute risk reduction. Quite the contrary, the actual explanation of why this drug is prescribed often makes healthy people think that they are in an imminent danger of a heart attack (stroke, fracture, etc) unless they take a drug.

And how good is this evidence for primary prevention anyway? For example, statins for primary prevention in women? What about all cause mortality? And what about conflicts of interests of the studies’ authors? Just recently a comparison between industry-sponsored studies and Cochrane reviews showed how different the results often are. Yet it is the industry-sponsored studies that often drive the guidelines. And guidelines change. What appeared to be true before turns out to be wrong later as new side effects emerge or the new studies find flaws in previous studies. And in the meantime many healthy people may be harmed.

So, the question is, should we be recommending interventions of proven benefit when patients are already on lots of other therapies for other problems, or should we minimize primary prevention for patients with established medical problems?
As I mentioned, the article wasn’t talking about patients with established medical problems but about healthy people. As far as whether or not you should recommend it, how about adequately informing your patients about both potential benefits and risks? How about not “framing” benefits to make them appear larger? How about presenting information objectively and not using meaningless statistics like relative risk reduction or the number of people who die of the desease every year? This is applicable to testing as well.

It’s all well and good to decry the overdiagnosis and overtreatment. But what specific diseases is the doctor suggesting we stop diagnosing and treating (he seems to think prostate cancer is a good candidate), obviously he’s not aware of the judgment against the doctor who had a patient give informed consent NOT to have the test, was later sued for it and lost because “it’s an easy test to get.”
Actually, the authors specifically mention liability fears as one of the reason for ordering tests. In his book, Dr H. Welch actually tells a story of his friend being sued for not ordering a routine PSA. I think the article aims to describe the situation for both doctors and lay readers, rather than make specific recommendations. I think adequate information about trade offs involved in testing may actually lead to less lawsuits and more sympathetic juries. Wouldn’t a juror who truly understands what overdiagnosis is and how it can harm be more understanding as to why it is not recommended or why a doctor hadn’t ordered it? Wouldn’t a juror who understands that even in some recommended tests early detection makes a difference in only a small percentage of cases be less likely to come up with huge awards when a test failed? I don’t know, but some doctors like Dr. L. Berlin who often writes about malpractice in mammography seems to think so.

As far as other tests are concerned, a recent study of annual checkups showed that more than half of them included non recommended tests and even some that USPSTF recommends against (routine urinalysis) . So I’d say doing tests that are not recommended would fall into the not doing category. As far as recommended tests are concerned, providing accurate information about benefits and risks to patients and “informing” them rather than “convincing” them may be the right thing to do. The authors aren’t against testing as much as against current mindset that people have to be scared, cajoled and convinced into testing, that there is no harm in testing, that testing is something “responsible people do” and not a personal choice. How often did you even tell people that overdiagnosis is a risk? How often do you tell “this will give you 1/500 chance that your life will be saved” instead of “this will reduce your chance of dying from the desease by n%” or even “more people survive for 5 years after diagnosis if this is diagnosed early” (what a surprise!)? If liability is your primary motivation to provide obviously misleading information, how can you explain so many doctors’ websites that convince people to be tested using exactly this misleading statistics and that fail to mention overdiagnosis as one of the risks? Many of these sites are authored by doctors. What risk of liability is in honestly discussing overdiagnosis on the websites or presenting probability of benefit in absolute numbers?
I think the article aim is simply to get doctors to ask questions about benefits and risks of turning healthy people into sick and at the same time to inform public about the issues.

OK you want a single person who’s been overprescribed? Here I am!

One day I had a blood sugar reading of 108 and it was considered normal. 3 months later the same reading of 108 was considered pre-diabetic and I was advised to begin a prescription.

I wasn’t any more likely to die of diabetes 3 months later than 3 months before. The bottom line is they keep lowering what is considered “healthy” so more and more people are fed drugs.

I was on statins, type 2 diabetes drugs, anti depressants, bladder control, allergy, and blood pressure. I have quit and I’m going to try to find a doctor who is not so much influenced by the latest study or the latest recommendation. Because those studies and recommendations are not worried about our health – they are worried about making more money for the drug companies.

I began watching my diet, getting more exercise and detoxifying my body from all the chemicals my doctor prescribed. She did it with the best intentions, but I felt like a lab rat.

How many times a year do we hear that what was considered healthy 20 years ago will kill us today? How do we know this stuff isn’t going to create worse problems 20 years from now? We don’t. Life is a gamble for us as it always was. I prefer to make my own informed decisions.