Too many diagnoses?


Category : Medical Rants

What’s Making Us Sick Is an Epidemic of Diagnoses

For most Americans, the biggest health threat is not avian flu, West Nile or mad cow disease. It’s our health-care system.

You might think this is because doctors make mistakes (we do make mistakes). But you can’t be a victim of medical error if you are not in the system. The larger threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses.

Americans live longer than ever, yet more of us are told we are sick.

How can this be? One reason is that we devote more resources to medical care than any other country. Some of this investment is productive, curing disease and alleviating suffering. But it also leads to more diagnoses, a trend that has become an epidemic.

This epidemic is a threat to your health. It has two distinct sources. One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don’t like, and in the past, this was considered a part of life. Increasingly, however, such sensations are considered symptoms of disease. Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction.

Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient.

The logical corollary of too many diagnoses is too many medications. As we make diagnoses, we too often prescribe medications. As the number of medications increases, so does the risk of side effects and interactions.

I agree with much of this essay. Our health care would probably benefit from a minimalist approach to prescribing. But if we make diagnoses, then we often feel obliged to use our prescription pads.

The problem that this essay describes is the problem of too many diagnoses for a single patient. Patients who have one problem have much less risk than those who already have several standard diagnoses.

Certainly this essay provides much food for thought.

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Comments (7)

I’m a patient, not a doctor, but I do have some opinions.
Too many diagnoses and communication failures? Yep. I have two inhalers (a “daily use” and an “emergency use”) from an enthusiastic and well-meaning doctor, who diagnosed me as having “preliminary” emphysema (is there such a diagnosis?) who noticed me breathing heavily and knew I am a smoker. In over a year, I have used the “Emergency” one once, and not the “daily” at all. You see, I know – and tried to tell him – that I was breathing heavily when he saw me because I was in pain and the breathing was as much psycholgical as physical: ten minutes after he saw me, I was breathing normally – and continue to do so except for those (alas too-frequent) times I am in pain ( from a circulation problem [PAD or PVD] which has a side effect of making my legs ache severely for several minutes after walking even from one room to another).

Understand,I am not averse to taking meds: I even took Coumadin (aka Warfarin, aka rat poison) for several months, while the doctor who prescribed it admitted to uncertainty about its applicability but we agreed to watch for results. Note that word – AGREED. I take several other meds more or less on faith because I am not educated enough to make a decision, but even with those I felt like a participant rather than a lab rat. Perhaps because (says the cynic) I am usually treated by interns who have not yet distanced themselves from learning about the patient as well as the disease.

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.”

I have a little different prospective. In speaking with people from other countries they describe their doctor visits as: How can we help you today. Problems are discussed, treatment plans made, and other services offered.

Contrast this with my experience in America where the first issue is: We need a complete physical so we can tell you what is wrong. Test are ordered, follow up appointments made, and a laundry list of prescriptions are given to solve potential problems that may be 20 years in the future. But don’t worry, your insurance will pay the bill and since you are now medicated under my care, we will see you every six months and do the whole thing over again.

The UK spends less than half what we do on medical care but has better longevity. While far from a perfect system doctors are forced to limit testing due to availability, and stick to a more selective group of prescriptions, while not having negative outcomes involving the general population.

Doctors in the US have confused medicating with medical care and ignore acceptable ranges in favor of some pharma invented lower limit. The questions should be: Is good, good enough? Will this medication achieve the desired results and improve the patients quality of life?

The current shotgun approach to medicate, medicate, medicate is only driving up cost and patients from doctors offices.

Steve Lucas

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.

Hi, this is my first time to a “blog” or website to converse so to speak.
You’re just a guinea pig for them to experiment on . Remember – the teaching students start on cadavers first. I’m in NY – and we have by far the worst hospitals anywhere – i don’t care what is published and by who .
I’ve lost faith in all doctors and NOW have the worst phobia of Hospitals i’ve ever had. I as taken into the ER after a domestic dispute with my spouse- and admit i had 3 glasses of wine (first i’ve had in 2years). Not thinking – i took one anti anxiety pill thinking that will at least help. Instead- it went to an all out brawl- he weighs 180 and i weigh 103. I’ve been on anti anxiety meds + all kinds of heart pills (CHF, Hypertension etc ) because of him .

I have CHF, COPD, LVD plus more -and can barely walk -but guess the stress, ETOH and pill brought it all out .
He slammed me around /sat on my chest -then called EMS told them i was trying to commit suicide-unfounded- but I was full of blood from being dragged on floor – elbow rug burns as big as dollar coins, sides of temples -same things from trying to hold my head still- grabbed me by back of shirt – almost strangled me -have marks on my neck from shirt collar-end all-(which no one at the hospital questioned ) I spent 1 day in psyche, 3 days in heart unit – yet the whole time at the hospital i complained about chest pains. (hospital believes spouse as he’s in postition of authority – civil service officer)
The few so called “dr’s” i saw had name tags backwards so not to see their names or titles- and ignored me if i asked a question.

All they did was take blood tests-for heart attack and blood ETOH level. Chest pains continued even after discharge -went to local Emergency clinic to find out i had 7th & 8th rib fractures-undiagnosed or x-rayed for. In order to be discharged- my spouse had to sign discharge papers -and could not mention abuse or i’d still be there. Think the few “dr’s” that “dealt” with me were interns or residents .
Dr. at local Emergency clinic was shocked when he saw the results of the x-rays – i had told him the truth – and he advised me off the record to get my medical records ,and contact domestic abuse – but i’m physically and socially (at present) in no position to contact domestic abuse.
I would rather have been arrested so i’d at least be able to bright situation to light in front of judge etc- couldn’t be worse than Psyche and cardiac student dr’s . Even my dr couldn’t believe how much damage had been done – since i’m so emaciated from the heart problems etc.Hospitals diagnosis is to sign up with THEIR 4 wk alcohol in patient program (we have excellent medical coverage)- “acute alcoholic”. My dr’s records /tests from office visits and hospital (surgeries.procedures) totally contradict the the Psche

I suffer now like a dog that’s been run over on the highway -worse than ever. Had 3x bypass few yrs ago- every yr -condition grows worse.

Does Anyone know if i can sue the hospital for not diagnosing the ribs. At present we live in same house – 2 different rooms. Presently have pneumonia diagnosed by my cardiologist -meds given and told him whole story- he knows from all the blood /lab work over the years i do not drink ETOH- just this once time. BAC was 1.5-thank god i can’t drive anymore -not that i would have . My doc wants me to go to hosptial -different one- for pneuemonia – possible Pulm. Emb- + he found something on a cat scan w/ IV contrast -… but fear is overwhelming. My credibility is gone with any kind of authority figures – except crisis unit – but they can’t help ??? Yes it was stupid of me to have the 3 glasses of wine- even one was too much – plus an anti anxiety pill- but i was consumed with such anger and nothing i could do about it over my spouse. I’ll be dead before a divorce goes through -and as i said – spouse is in civil service position of authority -with my back to the corner .
As for leaving the bum- no point now- I’m dying a little more each day – and feel i’ll just go with the flow. Made out advance directives already. LIKE I SAID – MY REAL QUESTION IS – NOT THAT I MAY LIVE LONG ENOUGH TO SEE IT THROUGH – BUT CAN THE HOSPITAL BE SUED FOR MISDIAGNOSIS.
If i’m on the wrong “website” or blog board -would appreicate guidance to right board and any advise

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.

To preserve your credibility, please don’t equate Restless Legs Syndrome to “twitchy legs”. RLS is a terrible condition that ruins entire lives.

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