Last week I read a book given by my lecturer in medschool, she lend me this book because she knew I would enjoy this book. And I did! She said at first she hesitated to tell me about this book because she’s afraid I might be rebellious to the physician that will teach me in hospital. Of course that wouldn’t happen I assured her, but it’s nice to have a counter-balance of perspective in thinking about medicine. The book titled “Overdiagnosed: Making People Sick in the Pursuit of Health” by H. Gilbert Welch, she did a superb research in making this book and the data are sound.
Long time ago, doctors only ask patients about their complain and did several physical examination in determining what disease they had. Then medical technology advanced until now we could see beyond our skin, X-ray is the most simple imaging modalities and commonly use to see fracture of bones, abnormalities in lungs, and screening. Doctors and patients have a lots of benefit from such examination in confirming the diagnosis made earlier. Other than X-ray today we have the more sophisticated CT-scan, it could determine the size and exact location of abnormalities anywhere in our body in 3D resolution. With X-ray we could only see “large abnormalities” but with CT scan we could see beyond that, we could see abnormalities that wouldn’t be seen in X-ray, even abnormalities that won’t actually matter to our health.
There’s a tremendous amount of benefit from these imaging modalities invention, but there’s also downside to it. It applies not only to CT-scan (which is used for diagnosis of lung cancer, brain cancer, etc.), but these “unnecessary finding of abnormalities” also happens in mammography (breast cancer screening), PSA (screening for prostate cancer). These examination constitutes for over 90% of cancer incidence in the world. Not only we (doctors) examine unnecessary abnormality, we also lower the threshold for diagnosis of diabetes and hypertension. More people today are diagnosed with diabetes and hypertension simply because these lower standard, dr. Welch argue that doctors participating in the panel to decide these standard are mostly biased by the benefit they got from pharmaceutical company. With more patients diagnosed, more drugs scripted, more commission for the doctor and of course, more profit for the pharmacy.
But let’s not judge or stereotyped doctors as pharmaceutical company pawn, there are more doctors with conscience than profit-oriented one. Sadly most of these “good doctor” stays on becoming a physician and the “profit-oriented doctor” become the one that write the rules. Dr. Welch also shares a story about his patients that got injured because of the unnecessary diagnosis (but fulfilled the guideline standard) he gave, the side effect of the drugs patient’s ate made him suffer from hypotension and lead to car crash. So, yes, diagnosis of a disease is necessary, but is it necessary to treat it radically? For some advanced disease, like hypertension with 200/100 blood pressure, the answer is yes. But how about for prehypertension with 130/90 blood pressure? Does the patient need drugs to stabilise the blood pressure or a lifestyle modification would be sufficient?
Overdiagnosed patients (those who got treatment but didn’t benefit from them) are patients who are more likely harmed than benefit from a treatment. Not all cancer patient will die because of cancer, and the psychological burden is tremendous. In the bigger view, over diagnosis also leads to more government burden due to unnecessary examination or treatment.
I’m not suggesting we ignore our complain of health, it does benefit to consult with doctor about our health, but is it necessary to do a screening every year? Prostate cancer screening for men, breast cancer for women, when there’s no symptoms of the cancer itself?
If you are interested in knowing more, I do recommend the book!
how about vaccine? would you believe in it too? Welch haven’t wrote about that.
No, I believe vaccination is important in improving the health of population and preventing several illness, particularly in children. I think the anti-vaccine movement is pretty stupid actually, considering the up to date clinical journal shows no negative side effect of a vaccine. Perhaps I’ll write about vaccine some other time, thank you for reading!