March 2, 2015


Healthy in a Falling Apart Sort of Way (JANE E. BRODY  MARCH 2, 2015, NY Times)

The widespread belief that medicine today has the potential to prevent most health problems or detect them early enough for a cure has succeeded in "medicalizing" modern life and raising the costs of medical care to unsustainable levels.

It has also prompted Dr. H. Gilbert Welch, a professor at Dartmouth Medical School, to write "Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care." A primary care physician and health policy wonk, Dr. Welch submits that too many people are being tested for too many things, being subjected to treatments they do not need and, in the process, being exposed to procedures that may do more harm than good.

One assumption, that all risks can be lowered, can create risks of its own. Case in point: A belief (sadly mistaken) that the measles vaccine is hazardous has sparked a mini-epidemic of a potentially life-threatening disease that had been eliminated from these shores 15 years ago.

Dr. Welch suggests focusing on reducing big risks and ignoring those that are average or lower. "Many health risks you hear about are exaggerated," he wrote. "Interventions to reduce average risks can create as many problems as they solve."

Another assumption, that it is always better to fix a problem than to manage it, has fostered a different epidemic: the ballooning and stenting of every coronary vessel found to have a partial blockage in patients with stable angina. However, as a randomized clinical trial showed, patients treated with medications to control blood pressure and cholesterol were no more likely to suffer a heart attack or die than those who underwent an angioplasty. Only if symptoms of cardiac pain persist is a more invasive procedure justified, Dr. Welch said.

Perhaps Dr. Welch's most controversial "assumption" is that detecting a potential health problem early is better than waiting until it produces symptoms. The value of screening people without symptoms is perhaps the most hotly debated issue in modern medicine. Should every woman over 40 have an annual mammogram? Should every man over 45 get an annual PSA test for prostate cancer?

It makes intuitive sense that early cancer detection and treatment are lifesaving. But what if the cancer would never have become a threat to life? To this day, I don't know if my cancer would have been deadly had I not had surgery and eight weeks of radiation. But once I knew it was there, I had little choice but to treat it.

Men with PSA readings on the rise face an even more challenging decision since definitive treatment, usually surgery or radiation of the prostate, can leave them impotent and incontinent.

Dr. Welch submits that sometimes early diagnosis does little more than turn people into patients for more years. "Action," he wrote, is not reliably the 'right' choice." Sometimes it's best to "don't just do something, stand there."

Posted by at March 2, 2015 3:26 PM

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