Friday, January 05, 2007

What's Making Us Sick Is an Epidemic of Diagnoses

You might think this is because doctors make mistakes (we do make mistakes). But you can't be a victim of medical error if you are not in the system. The larger threat posed by American medicine is that more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses.

Americans live longer than ever, yet more of us are told we are sick. How can this be? One reason is that we devote more resources to medical care than any other country. Some of this investment is productive, curing disease and alleviating suffering. But it also leads to more diagnoses, a trend that has become an epidemic.

This epidemic is a threat to your health. It has two distinct sources. One is the medicalization of everyday life. Most of us experience physical or emotional sensations we don't like, and in the past, this was considered a part of life. Increasingly, however, such sensations are considered symptoms of disease. Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive now become diagnoses: sleep disorder, depression, restless leg syndrome and sexual dysfunction.

Perhaps most worrisome is the medicalization of childhood. If children cough after exercising, they have asthma; if they have trouble reading, they are dyslexic; if they are unhappy, they are depressed; and if they alternate between unhappiness and liveliness, they have bipolar disorder. While these diagnoses may benefit the few with severe symptoms, one has to wonder about the effect on the many whose symptoms are mild, intermittent or transient.

The other source is the drive to find disease early. While diagnoses used to be reserved for serious illness, we now diagnose illness in people who have no symptoms at all, those with so-called predisease or those "at risk."

Two developments accelerate this process. First, advanced technology allows doctors to look really hard for things to be wrong. We can detect trace molecules in the blood. We can direct fiber-optic devices into every orifice. And CT scans, ultrasounds, M.R.I. and PET scans let doctors define subtle structural defects deep inside the body. These technologies make it possible to give a diagnosis to just about everybody: arthritis in people without joint pain, stomach damage in people without heartburn and prostate cancer in over a million people who, but for testing, would have lived as long without being a cancer patient.

Second, the rules are changing. Expert panels constantly expand what constitutes disease: thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity have all fallen in the last few years. The criterion for normal cholesterol has dropped multiple times. With these changes, disease can now be diagnosed in more than half the population.

Most of us assume that all this additional diagnosis can only be beneficial. And some of it is. But at the extreme, the logic of early detection is absurd. If more than half of us are sick, what does it mean to be normal? Many more of us harbor "pre-disease" than will ever get disease, and all of us are "at risk." The medicalization of everyday life is no less problematic. Exactly what are we doing to our children when 40 percent of summer campers are on one or more chronic prescription medications?

No one should take the process of making people into patients lightly. There are real drawbacks. Simply labeling people as diseased can make them feel anxious and vulnerable - a particular concern in children.

But the real problem with the epidemic of diagnoses is that it leads to an epidemic of treatments. Not all treatments have important benefits, but almost all can have harms. Sometimes the harms are known, but often the harms of new therapies take years to emerge - after many have been exposed. For the severely ill, these harms generally pale relative to the potential benefits. But for those experiencing mild symptoms, the harms become much more relevant. And for the many labeled as having predisease or as being "at risk" but destined to remain healthy, treatment can only cause harm.

The epidemic of diagnoses has many causes. More diagnoses mean more money for drug manufacturers, hospitals, physicians and disease advocacy groups. Researchers, and even the disease-based organization of the National Institutes of Health, secure their stature (and financing) by promoting the detection of "their" disease. Medico-legal concerns also drive the epidemic. While failing to make a diagnosis can result in lawsuits, there are no corresponding penalties for overdiagnosis. Thus, the path of least resistance for clinicians is to diagnose liberally - even when we wonder if doing so really helps our patients.

As more of us are being told we are sick, fewer of us are being told we are well. People need to think hard about the benefits and risks of increased diagnosis: the fundamental question they face is whether or not to become a patient. And doctors need to remember the value of reassuring people that they are not sick. Perhaps someone should start monitoring a new health metric: the proportion of the population not requiring medical care. And the National Institutes of Health could propose a new goal for medical researchers: reduce the need for medical services, not increase it.


Another waste of health dollars by government

A MULTIMILLION-dollar hyperbaric chamber built at the Royal Brisbane and Women's Hospital more than four years ago has never been used. Although demand for hyperbaric medicine has soared in Queensland in recent years, the chamber is unlikely to treat its first patient until next year. The Government yesterday defended its decision to refer public patients requiring decompression treatment to the Wesley Private Hospital as a better use of taxpayers' money.

Health Minister Stephen Robertson's spokesman said to commission and then operate the RBWH chamber for a year would cost $1.7 million. The Wesley Hospital provided the service last year for less than $1 million. "Until now, it's been cheaper to go through the Wesley . . . than to commission the one at the RBWH," [An interesting confession!] he said. "We're actually saving taxpayers' money." The Wesley has treated Queensland Health patients recommended for decompression treatment since 1998.

When asked why the Beattie Government had decided to build the RBWH hyperbaric chamber in the first place, Mr Robertson's spokesman replied: "I've got no idea." The chamber was built when Wendy Edmond, who has since retired from politics, was health minister.

The number of public patients treated in the Wesley hyperbaric chamber has almost doubled in three years, from 1083 in 2002-02 to 2097 last year. In 2002-03, the hospital treated 1083 public patients in its chamber but by last financial year, that had swelled to 2097.

Decompression chambers are used to treat a variety of patients, not just divers suffering from the bends. Patients who have had surgery on blood vessels are sometimes put in a hyperbaric chamber to assist in the repair of oxygen-starved tissue. Decompression treatment is also covered by Medicare in cases of difficult-to-heal wounds.

The Opposition and the Australian Medical Association Queensland both condemned the Government for building the chamber and then failing to use it. "It's crazy," said AMAQ president Zelle Hodge. "You'd have to ask why didn't someone do an appropriate cost analysis before this was built." [He's joking. Governments don't do that if it seems good for a self-inflating press-release at the time] Opposition health spokesman John-Paul Lanbroek accused the Government of mismanagement. "We've got this hyperbaric chamber that's supposedly the best in the southern hemisphere. What do we have to do to get it up and running as it should be for Queensland patients?" he said.

Mr Robertson's spokesman said the Minister last month had signed approval for Queensland Health to explore the possibility of running the RBWH hyperbaric chamber as a public/private partnership with a view to have it operational by 2008.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Pages are here or here or here.


No comments: