PREVENTING OVERDIAGNOSIS 2015
PREVENTING OVERDIAGNOSIS 2015
Two years ago, I wrote that the first “PREVENTING OVERDIAGNOSIS” conference was easily the most important meeting I had ever attended.
Last week's third “PREVENTING OVERDIAGNOSIS” conference, held at the National Institutes of Health in Washington, DC was even better. The conference was sponsored by the National Cancer Institute in collaboration with Oxford University, the British Medical Journal, Consumer Reports, and Bond and Dartmouth Universities. Hundreds of presentations covered the causes, consequences, and cures of overdiagnosis from every conceivable angle and laid out an agenda for future action. The international audience of 350 was as bright a group as I have ever encountered in almost 50 years of attending medical meetings.
The topic is the highest priority public heath problem we face in the US and increasingly around the world. Medical mistakes are the third leading cause of death in the US--and are often occasioned by excessive testing and treatment delivered in an uncoordinated way by doctors who know lab tests, but don't know their patients.
Clearly, too much medicine can be very bad for your health. And it is also a disaster for the health of our economy. The US spends $3 trillion a year on heath care- more than the GDP's of all but four countries in the world. Because one third of this enormous investment is sheer waste, it is no surprise that we get lousy outcomes compared to countries that spend much less, but spend much more wisely.
The biggest culprit in overtreatment is over testing. We have developed sophisticated technology that discovers incidental "diseases" that would have little or no impact on our lives and then treats them with disproportionately blunderbuss interventions that often cause more harm than good. Rates of breast, prostate, and thyroid cancer increased dramatically not because people are sicker, but because disease definition has been broadened to inflate diagnosis. Much of what is now called "cancer" is not really cancer at all, or so slow growing that it is not really health or life threatening.
Aggressive treatments that are delivered for non-aggressive "diseases" cause more problems than they solve. Our current excess of therapeutic zeal follows a long historical tradition of well intended, but overly exuberant, doctors harming their patients with really terrible treatments. Not so long ago, doctors routinely bled their patients, gave them emetics and cathartics, and poisoned them with heavy metals. Future observers of our current practice will find some of what we are doing now equally wrong headed and harmful.
Diagnostic inflation has also resulted in overtreatment of diabetes, hypertension, osteoporosis, attention deficit disorder, most problems that lead to orthopedic surgery, and lots more of what constitutes everyday medical practice.
Overtreatment is driven by many powerful and interacting forces and will be difficult to tame.
Most destructive has been the commercialization of medicine as a big business-- healing art transformed into profitable cash cow. Perverse financial incentives encourage disease mongering, false advertising, over testing, quick diagnosis, and unnecessarily aggressive treatment.
Often the best medical decision is to cautiously watch and wait, but this is discouraged by reimbursement mechanisms that favor quickly jumping in with potentially harmful, very expensive, and often unnecessary treatments. The powerful medical-industrial complex will exert all its considerable financial and political might to protect its profits, even if this means compromising patient welfare and eating up the economy. The obvious solution here is to substitute capitation for crazy fee-for-service incentives that reward the health system for doing more.
Too much medicine has also been driven by a medical research enterprise that systematically rewards scientists, journals, and the media for hyping often-false positive findings. Negative findings that would encourage the public to have a healthy skepticism about exaggerated claims are buried.
The result: patients accept, and even clamor for, testing and treatment that is more likely to harm than help. People fear the risks of illness too much and fear risks of treatment far too little. A great deal of conference time was thus productively devoted to the communication tools necessary to help right this imbalance. Patients must become informed consumers to balance the benefits of treatment with its risks and protect themselves from a system pushing them to always want more than may be good for them.
Regulators of medical excess no longer regulate. Seven years ago, the FDA approved only one third of drug applications. This year, it has approved 96%.