Your doctor is there for you, even when you aren’t sick

A long-held precept of public health has been that prevention and early detection are “good things”. We’ve always known that early detection (screening) is a tough nut to crack. Some conditions yield easily to our screening practices, some do not. Some diseases, when detected early, behave no better than when detected late. The course of hypertension, for example, is much more likely to be benign when detected early. Screening for lung cancer is much less satisfying. If xrays or CT scans are used in a general population, they are not effective at discriminating sick people from well. However, like most screening problems, the higher-risk the population, the more useful the testing. We still haven’t found a good answer to lung cancer screening, but we do know that screening people already at higher risk is more likely to be helpful. The problem here, as with prostate cancer, is when we find a problem in otherwise healthy people, we may do more harm poking around than if we had just waited for the disease to pop up on its own. Many men with abnormal prostate tests go through painful and potentially dangerous testing that doesn’t help extend their lives. But for other men it does. The trick is figuring out which men really do benefit from early detection.

A recent Op-Ed piece in the New York Times gives a distorted view of what we primary care physicians do, especially when it comes to screening. If he is trying to help us see the need for a revolution in medical care, he has failed and failed dangerously.

The basic strategy behind early diagnosis is to encourage the well to get examined — to determine if they are not, in fact, sick. But is looking hard for things to be wrong a good way to promote health? The truth is, the fastest way to get heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or cancer … is to be screened for it. In other words, the problem is overdiagnosis and overtreatment.

Um, well, yeah but…something is wrong with this statement. It is a statement that sort of re-states something called “lead-time bias,” that is a disease seems more prevalent if we work hard to find all the people with the disease as early as possible. If you don’t know about your diabetes, then as far as statistics are concerned, you don’t have it and the number of diabetics is one fewer. Does this mean that “the problem is overdiagnosis and overtreatment?” In this case, the problem is over-generalization and over-simplification.

Early detection of many diseases is in fact a good thing, although the author argues that early detection “doesn’t promote health but promotes disease.” This is, in a word, insane.

He states that “there is a concern about too much detection and treatment of early diabetes,” an incorrect, or at least simplistic reading of the evidence he cites. There is not yet a randomized controlled trial showing that population-wide screening and early treatment for diabetes is cost-effective and whether it reduces the well-known and devastating complications of the disease. It is known, however, that once it is detected, treatment significantly decreases the risk of heart attack, stroke, blindness, kidney failure, amputation…you know, important stuff. When populations are studied to assess the effects of high blood sugars, a continuum is found between people with normal sugars and those with higher and higher sugars. Diabetes begins its destruction early. Is stopping it earlier better? Is it ethical to do a randomized controlled trial to see, given the clinical plausibility of earliest intervention? Especially when that intervention is often exercise and dietary modification?

The author, Dr. Gilbert Welch, is selling a book called Overdiagnosis, but he makes a poor case for his thesis:

For years now, people have been encouraged to look to medical care as the way to make them healthy. But that’s your job — you can’t contract that out. Doctors might be able to help, but so might an author of a good cookbook, a personal trainer, a cleric or a good friend. We would all be better off if the medical system got a little closer to its original mission of helping sick patients, and let the healthy be.

It may be “your job” to keep yourself healthy, but you aren’t always good at it and neither am I when it comes to my own health. Studies show that being counseled by your doctor to quit smoking helps. Public health campaigns help too, but it’s not the same as a face-to-face encounter. Reading a cookbook or listening to a cleric is not the same is a comprehensive visit to a doctor who can lay out what you need to do to stay healthy and who can help stop diseases before they claim you. This is both obvious and supported by the evidence.

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  1. D. C. Sessions

     /  March 18, 2012

    Timely, this. Just had my annual and the usual friendly chat with my PCP. And I’m reminded of a possibly-useful thing he does.

    Every year based on the exam and history he pulls up the actuarial stats for me. Am I in the “median expectancy of 85” group or the “you’ll be doing well to make 70” group? So far, I’m still pushing out the horizon — which is what you’d expect as long as nothing changes. I’ll push it out faster if I can lose 40 or 50 pounds, but otherwise good.

    We talked about the fundamentally statistical nature of all the rules, though, and if my blood chemistry starts to trend in the wrong direction, pushing the actuarials down, he’s going to have a Hell of a handle to get me to kick up the weight control several notches — and $HERSELF will cut me no slack at all.

  2. “A recent Op-Ed piece in the NYT gives a distorted view…” Yay! Ross Douthat deconstruction! Oh, wait.. there’s another one?!

    Dr Welch doesn’t look old enough to have been steeped in the uneducated suspicion and early 1900s medical technology ineffectiveness that informed my grandparents’ sketchy medical decisions, but his reasoning sounds an awful lot like theirs.

    Do clerics prescribe birth control now? Did anyone tell Santorum et. al.? He would be outraged by this news.

    If I don’t go to the doctor for birth control, and later don’t go for a pregnancy test, does that mean I’m magically not pregnant? Read the cookbook laydeez! Put a biscuit between your knees.

    I’m a little tired of men telling me not to see my doctor….

  3. Sorry. I thought I was done, but I’m not.

    When I take my kids in for well-cild checks (and vaccinations!) I run the risk that their pediatrician will detect some serious problem early enough to actually treat it? Is this supposed to be a bad thing?

    • Chris

       /  March 19, 2012

      I hope not. I brought my then fourteen year old son in for a tetanus booster and well child check up. The family doctor heard a heart murmur, and then ordered an echocardiogram.

      It turned out that his heart muscle had grown abnormally, and he had hypertrophic cardiomyopathy. It is life threatening, one of the most common causes of sudden cardiac deaths in young people. A twelve year old died of it suddenly during a track meet just the week before in a nearby community.

      For nine years he did okay with medication, but it has gotten worse. We are waiting for the hospital to tell us when his surgery can be scheduled.

  4. Vicki

     /  March 21, 2012

    Even if it’s my job to keep myself healthy, how does this person expect me to know what I need to do? I can’t glance in the mirror and know what my blood sugar is like. Yes, we can check our own blood pressure—that it’s a free service at the local drugstore, or I can buy a home monitor, doesn’t mean it’s not a medical test.

  5. Gina

     /  March 22, 2012

    Patient’s Right’s surrounding the “State” in the case the State of WA and the DEA’s war on Opiate Drugs has just been kick up into the realm of Fascism. To” protect” me in preemptive sweeping change of all my medication to prevent possible future harm a pain management specialist will be taking me off all the “high risk” drugs , not limited to opiates, generic drugs, and prescribing for me with out my consent or choice other than to go through a dangerous withdraw with out medical support, new Patented Drugs that are better for me. And his commissions. These are drugs it took 5 years working with another series of specialist to find what works for me. I have a documented 20 year history with these drugs with now contraindication issues . Now with the new regulation that just went into effect Jan. 1, 2012. I am forced to see this specialist as my PCP will not prescribe for me. I believe several other State adopted the same regulations this year. If this is not tyranny I do not know what is. It begin with smaller target populations and little by little insidiously creeps into the live of the many. Fascim in the USA is here and increasing. Just wait for Obamacare to take effect!

    • I have no idea what you mean.

      • Gina

         /  March 22, 2012,%202012.aspx
        The reality of the effect of these new regulations are not as they appear in the letter of the law. What is really happening with patient is something all together more ominous. .We are forced to see Pain Management Specialist. Before we are allowed to see the Pin Management Specialist we must sign away our right to decide if we want to take a new medication for other disorder’s that have been handled by specialist in the field of medicine the prescription drug is normally monitored by and release our choice to the pain manger’s policy. Specifically, for 20 years I have taken benzodiampam’s for PTSD and Panic Disorder. A psychiatrist monitors these medicines. I take Morphine Equivalent Dosage @ 50 mgs total for chronic pain for a degenerative spinal condition. It is mandatory I go to a pain specialist this year. The problem is this Dr. who specialty is pain management has his own rules. I must be taken off all those medications and take what he decides is appropriate for me. I have now recourse but to submit to his rules as my other Dr’s. gave notice they will cease prescribing for me because of the Clinic’s new policy. something I have not been given to read although I have requested it. Everyone else I know has to follow these rules as well no matter the clinic.

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