For
most in the western world,
the biggest health threat
is not avian flu, West Nile
or mad cow disease. It’s our
health-care system.
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 traditional
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.
We are living longer than
ever, yet more of us are
told we are sick.
How can this be? One reason
is that the western world
devotes more resources to
medical care than other
countries. 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.