Medical science is making such remarkable progress that soon none of us will be well.
The just completed conference “Preventing Overdiagnosis” was easily the most important meeting I ever attended. Sponsored by the British Medical Journal, Consumer Reports, and Dartmouth and Bond Universities, the goal was to identify the excesses in medical care and to figure out how to correct them.
The evidence is compelling that we in the developed countries (especially the US) are overtesting for disease, overdiagnosing it, and overtreating. Wasteful medical care of milder or nonexistent problems does more harm than good to the individual patient, diverts scarce medical resources away from those who really need them, and is an unsustainable drain on the economy.
The causes of medical excess are many and powerful. Here is a truncated list:
• With very few exceptions, the early screening and intervention touted by preventive medicine has turned out to be an oversold, dangerous, and expensive flop.
Routine PSA screening for prostate cancer is the clearest example. It used to be recommended that men of a certain age be tested yearly. It is now recommended that the test not be done at all unless a man has a family history or other special risk factors.
Why the big change? Definitive long-term studies prove that the test doesn’t save lives and instead ruins them by triggering invasive interventions with painful complications. Screening is usually too late to stop fast spreading tumors and too good at identifying slow growing ones that don’t count and are better left alone. If they live long enough, the majority of men will develop an incidental and benign prostate cancer before they die from something else. Picking up these tumours early causes great grief for no return.
• Lowering the thresholds of disease definitions has identified diseases that don’t exist. The dream was that getting there early would help prevent the development of severe heart problems, hypertension, diabetes, osteoporosis, and a score of other illnesses. The reality is that getting there too early misidentifies too many people who are not really at risk and then subjects them to needless and harmful tests and treatments
•The technology is out of hand. If we do enough CT scans we can find structural abnormalities in just about everyone. But most findings are incidental and don’t have any real clinical meaning. Paradoxically, lots of otherwise healthy people will get dangerous cancers from the CT radiation that served no useful purpose.
•Doctors have gotten into the habit of ordering huge batteries of laboratory tests and treating the results while ignoring what is best for this particular patient. There needs to be retraining of those already in practice, a change in how medicine is taught to new doctors, and a realignment of financial incentives to promote best care—not excessive care.
•Except for hospice care, it has become almost impossible to die in a dignified, humane, and cost effective way. Hospitals have become frenetic torture chambers that make dying much worse than death and cost an obscene fortune.
Curing medical excess will not be easy. Harmful overtesting and overtreating is promoted and protected by the enormous economic and political power of the medical industrial complex. Here’s just a beginning list of what needs to be done:
•Tame and shame Big Pharma. Stop the direct to consumer advertising that is allowed only in the US and New Zealand. Prohibit all Pharma contributions to professional associations and consumer groups. Regulate and make transparent all the marketing ploys used to mislead doctors. Force the publication of all clinical research trial data.