I’d like to go off on an (important) tangent and comment on overdiagnosis in medicine. MISdiagnosis gets it wrong. With OVERdiagnosis, the doctor gets the answer right, but it’s beside the point—studies show the information provides no benefit (or fail to show any benefit) to the patient.–thus, a waste of time, effort, anxiety and money. I read a review article (its technical, but if you’d like you can see it here) and will summarize some findings:
- Gastroesophageal reflux in infants—medications do not seem to provide any benefit and there is evidence that it increases the risk of respiratory infections. The condition almost always resolves spontaneously by 12 months
- Newborn jaundice—we test and hospitalize children for this condition far more frequently but there has been no change in death or brain damage rates from this condition since 1979
- Bronchiolitis—despite far greater rates of hospital admission and treatment with oxygen since 1980 (with the use of pulse oximeters—the clip on your nail used to evaluate blood oxygen levels) no change in infant mortality rates in that time. No benefit to patents has been demonstrated from administering oxygen to treat transient, mildly low oxygen levels.
- ADHD—in all grades the youngest children tend to have the highest incidence of being diagnosed with this condition
- Obstructive sleep apnea—Tonsillectomy and adenoidectomy (T+A) treatment with this procedure has increased from 12-77% from 1970-2005. Studies have shown no benefit in executive function or attention in children after undergoing T+A.
- Urinary tract infection—medical and surgical treatments for chronic UTI have shown no decrease in the rate of renal scarring or insufficiency; even severe problems seem to resolve spontaneously over time.
- After age 70, 80% of men are found to have prostate cancer at autopsy. The mortality rate from this condition is 3%.
- A Canadian study of over 90,000 women followed over 25 years found no change in mortality rates in women diagnosed by screening mammography compared to women who did not have that procedure.
There are so many factors driving overdiagnosis—from the way young doctors are trained (a lot of positive emphasis on diagnosing the strange or obscure) to patient expectation (who among us does not have that friend or relative who seems to equate having a symptom with taking a pill or getting a test?). People, including doctors, become confused by the data. One example is “lead time bias.” Illustration: a hypothetical medical condition; people who are screened are diagnosed on average by age 75, not screened diagnosed at 78. The study shows both groups die about age 80—so the screened group lives, on average, 5 years longer after being diagnosed compared to the unscreened group’s 3. But since they all die at about the same age, there is no actual benefit in life expectancy, so what’s the point? The above scenario is NOT an uncommon situation.
And there’s LOTS of money driving overdiagnosis. The drug industry spent $4.5 billion on direct to consumer advertising in 2009. Expert panels setting treatment guidelines for many chronic illnesses (eg depression, ADHD, high cholesterol) are populated by specialists with strong financial ties to companies providing therapy and testing technology. Kimberly Clark—the makers of Depends adult diapers—has been a major sponsor of prostate screening clinics (incontinence is a common side effect of treatment). And it costs lots of money too—the Institute of Medicine estimated that 31% of US medical expenditures ($765 billion!) is waste. Who thinks saving 31% on health insurance would not be a big deal?
None of the above proves anything about any particular disease. People should always consult their doctor for their problems and concerns. But try and be informed (from reputable sources—remember, the internet is “the Wild West” of information). As an old commercial used to say, “an educated consumer is our best customer.” We doctors need to be able to explain to you patients not only WHAT we are doing, but also specifically HOW and WHY it will help you.
As always, I invite questions or comments, including suggestions for future posts. Thanks for reading.