Here’s a question to ask your doctor: Have you ever had a patient who suffered from getting too much medical care? Assuming she has the time and the inclination to talk, I bet you’ll hear an interesting story.
A 2011 survey of American primary care physicians found that nearly half thought their patients received too much medical care. Remember, that’s doctors talking.
Medical interventions toward the end of life are probably the most familiar example of too much medical care. Death is often preceded by multiple visits to the hospital or prolonged stays, which typically involve procedures and interventions. These may or may not lengthen life, but they almost certainly make it more painful.
For the last 25 years, I have examined the other end of the spectrum: too much medical care among those who are well. In the past, people sought medical care because they were sick. Now we encourage the well to get examined to determine if they are not, in fact, sick.
Old doctor joke: What is a well person? Someone who hasn’t yet been thoroughly examined.
My work focuses on cancer screening (which means checking seemingly healthy people for signs of hidden cancer) and its disturbing side effect: cancer overdiagnosis. It turns out that for some cancers — particularly breast cancer, prostate cancer, thyroid cancer, and melanoma — the number of people who have it is a function of how thoroughly we examine them. The harder we look, the more cancer we find. Yet most of these extra “cancers” are less likely to affect health.
In an article in last week’s New England Journal of Medicine, a colleague and I examined these four cancers. We found that one group of Americans — the affluent — were at particularly high risk for being diagnosed with them.
Don’t make the mistake of thinking the affluent are genuinely at higher risk for these cancers. They aren’t. Their death rates from these cancers are similar to everybody else’s. Instead, they are at higher risk of being overdiagnosed because they are so thoroughly examined.
This isn’t exactly breaking news. Earlier this year, in a careful analysis of breast cancer diagnoses in northern California, the investigators found that socioeconomic status mattered. Compared to women with low socioeconomic status, those with the highest were roughly twice as likely to have been diagnosed with breast cancer, even after controlling for individual risk factors like family history, age of first period, birth history, hormone therapy, alcohol use, and the like.
Why is this happening? Chalk it up to more thorough examination: more mammograms, more 3-D mammograms, more ultrasounds, more MRIs. And that adds up to more overdiagnosis. According to a recent investigation, the effort to detect progressively smaller cancers selectively identifies tumors that are biologically prone to grow slowly, if they grow at all — in other words, tumors that would never have affected health, quality of life, or longevity.
Once you understand the problem of cancer overdiagnosis, it’s easy to imagine the problem extending to other diseases. There are a lot more abnormal coronary arteries out there than there are people with symptomatic heart disease. The same holds true for herniated discs detected on CT scans among people without back pain. And we are all developing attention deficit disorder (click here).
The truth is that we all harbor abnormalities. And diagnostic tests are increasingly detecting them. It’s a process that could turn all of us into patients. Too much testing begets too much treatment, which leads to too many people suffering from unnecessary medication side effects, complications from procedures, and sometimes even death.
Some of the resistance to moving toward a more sustainable (and affordable) health care system comes from people who fear they will be forced to give something up. But to get safer and more affordable health care, all we need to give up is too much medical care.
More and more doctors understand these problems but feel trapped in a system that rewards them to do more. There’s a lot of money on the table to do just that — money in developing new tests and money in producing new patients to use them on. And some doctors find it hard to buck the conventional wisdom that more medical care is better because we assume it’s what our patients want.
If you do ask your doctor whether she has ever had a patient who suffered from getting too much medical care, it just might give her permission to change the way she treats you.
Gilbert Welch, MD, is professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and author of “Less Medicine, More Health” (Beacon Press, 2015).
Interesting point, I suppose. But, wouldn’t you agree that neglect far outweighs excessive care in the US in 2017? I mean FAR outweighs? Yes, there is some small portion of people who are consuming more E/M time with physicians than the common person would think prudent, but the REAL problem in the US healthcare system is that 75% of people do not seek care soon enough, in my opinion.
Thank you for the insightful article. What are your ideas for determining the optimal level of care for patients, whether individually or collectively?
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