Dangers of Overdiagnosis
Allowing yourself to get caught in and harmed by today’s broken American health system is relatively easy: simply let yourself be diagnosed with something that has never caused you symptoms and will never lead to your death. You will not be alone. Americans today are overdiagnosed by the millions. Then they are treated, mostly with drugs, but also with procedures. Many experience harm. All experience the subtle psycho- logical change that moves them from well person to patient.
Dr. Gil Welch, an authority on the effects of medical screening and former head of Dartmouth’s Institute for Health Policy and Clinical Practice, defines overdiagnosis this way: “Over-diagnosis is when individuals are identified, labeled, and treated for conditions that will never cause symptoms or death.” That’s worth a few moments of meditation.
By the time they are fifty, most Americans are on prophylactic or symptom-suppressing medications—typically antihypertensives for blood pressure, statins for “hyperlipidemia”, medications for prediabetic high blood sugar, or much worse, blood thinners for atrial fibrillation, or immunosuppressants for GI conditions, skin conditions or arthritis. As we have said, 60% of American adults now live with the diagnosis of at least one chronic condition.
This wasn’t true a couple of generations ago. One reason is that the standards for defining all these diseases have been tightened year after year in the name of prevention. But as that happens, more people can become permanent patients and revenue generators. The goal posts for being diseased have been moved without our knowledge or consent, or more importantly, our primary care provider’s consent.
On the diabetes front, for instance, the definition of a type 2 diabetic used to be a fasting blood sugar over 140 mg/dl. Now it’s 126 mg/dl, turning 1.6 million people into permanent “diabetes patients.”
Isn’t this good, you ask? Aren’t we preventing bigger problems later on?
Certainly, in the case of extremely high blood sugar, the risk/benefit ratio makes medicating appropriate. But in mild cases, it is much less clear. Statistically speaking, the number of people you need to treat to prevent one person from getting worse is often in the hundreds.
Then, there is the fact that each of these prophylactic treatments has a possible long-term downside even beyond its short-term side effects. As the threshold for diagnosing many common conditions comes down, there are four societal effects: 1) millions more people become permanent patients, 2) billions of dollars pour into the coffers of pharmaceutical companies, 3) thousands of patients suffer side effects for every person helped, and 4) many people are harmed or have their lives shortened. Iatrogenic disease expert Dr. Gil Welch illustrates why medicating borderline patients is not always good:
This is not a happy story. Mr. Roberts was a seventy-four-year old man whose major medical problem was ulcerative colitis, but well managed. One day, in a routine lab test, Mr. Roberts was found to have elevated blood sugar. It wasn’t that high, but the finding prompted more testing.
And more testing confirmed the diagnosis: diabetes. He had type 2 diabetes. … Although he had no symptoms of diabetes, over the past few decades, doctors had gotten much more aggressive about treating it early, so his primary care physician started him on glyburide—a drug that lowers blood sugar. The medication worked well. Six months later he blacked out while driving on the local interstate. His car went off the road and rolled over. … The medication had worked too well. I’d hate to have been the doctor who prescribed him glyburide.
But I was that doctor. Mr. Roberts was in the hospital for over a month. … I felt terrible. It goes without saying—I didn’t restart the glyburide. Mr. Roberts is now ninety and still a patient of mine. He has not been treated for diabetes since the accident, nor has he had any complications from diabetes. I think he was overdiagnosed. But he was lucky. There was no permanent injury.The same thing is happening with what is now called elevated blood pressure. It’s clear that out-of-control blood pressure, let’s say 200 systolic/115 diastolic, can lead to strokes, heart failure, kidney damage, and eye hemorrhage. But today, elevated blood pressure is defined as anything over 120/80. In their defense, most physicians wait to see a rising pattern, take the pressure multiple times, and employ other cautions before prescribing. But the new protocols are staring them in the face and making them less conservative.
There is a concept in medical research called “number needed to treat.” For example, you need to treat nineteen patients with borderline hypertension to reduce the chance of an event like a stroke happening in one patient. So if you are diagnosed with borderline hypertension and get on medication, you can be one of the lucky 6% who actually benefit in some way. The rest, 94%, will not benefit. And the market for prehypertension is even larger than for prediabetes, some eighteen million Americans. You are on the medication for years—as long as your physician can persuade you to take it.
Meanwhile, the longer you take these medications, which are usually diuretics, various ACE inhibitors, calcium channel blockers, or beta blockers, the more you are exposed to their long-term effects. Some diuretics, for instance, make it harder for your body to maintain potassium balance, putting stress on your heart. ACE inhibitors interfere with your body’s ability to constrict blood vessels. Beta and calcium blockers can prevent your heart from responding to increased demands for blood by beating faster. None of these classes of drugs address the underlying blood pressure problem, whatever that may be. All of those side effects may be worth it in cases of severe hypertension, but in cases of borderline hypertension, it is unclear if the risks of these drugs outweigh the benefits.
Here’s what to do about this if you are diagnosed with borderline hypertension: work with your doctor to understand what class of hypertension you fall into and the class of drug you will receive. Ask for any benefit studies that might exist in your class with the suggested treatment. Study the numbers if any can be provided. Ask about lifestyle changes you can make first. Then make your own informed decision.
In the US, over 5.2 million people are estimated to be living with A-fib, as it’s often called.
But A-fib is a condition being diagnosed more frequently and rising fast in public consciousness, partially due to large investments in advertising by the makers of anticoagulants like Eliquis. There’s a battle for the top spot in the growing blood thinner market, and A-fib is the top application. The reservoir of possible patients seems almost limitless. But here is the dilemma with A-fib and blood thinners for the medically wise person. It is widely quoted in the advertising for anticoagulants that A-fib increases the risk of a stroke by up to five times above the gen- eral population. But this is a classic generalized relative risk statement. . Firstly, if you have this condition, your actual riskvaries widely depending on many facts—a new “CHADS score” helps cardiologists get to your personal risk.
But secondly, and more importantly, you need to know your absolute risk. As best as you can determine, what is the actual percentage of likelihood that A-fib patients like you will have a stroke this year? And then, if you decide to take one of the new blood thinners to reduce your risk, by how much will it reduce your risk?
And then, what is the absolute risk for a serious or fatal bleeding event on this medication? Is the absolute risk of a bleeding event higher or lower than your risk of a stroke? These are legitimate and important questions for you. The wise patient takes note of the fact that this information is not easily available either to physicians or patients at this writing. The medically wise person tries to get a handle on the facts before starting a blood thinner medication, which is a serious and powerful drug.
Now, we finally come to the most risk-laden class of commonly prescribed drugs—ones on which to exercise much medical wisdom before taking. These are the heavily advertised immunosuppressants such as Xeljanz, Humira, Cosentyx, Azasan, Arava, Orencia, Enbrel, Remicade, and Rituxan, to name a few. They are marketed for serious autoimmune conditions like lupus, rheumatoid arthritis, Crohn’s disease, and multiple sclerosis. They are also being marketed for less serious but distressing conditions such as alopecia and psoriasis. The marketing is a combination of lawyer-like wording (Humira may lower your ability to fight infections) and recitations of dire complications and side effects, repeated so often that TV viewers become inured to them.
Immunosuppressants are not new. Organ transplant patients know they have to live with the threat of these complications for the rest of their lives. What is new is that people like you and me are willing to trade off the risks of a suppressed immune system against the hope that we will be lucky and not have serious complications. These drugs have been certified safe and effective by the FDA, but every physician knows that prescribing certain immunosuppressive drugs puts their patients at an increased risk of serious infections, cancer, and cardiovascular disease. And while the side effects are required to be mentioned, their incidence rate is much harder to find. Try to find data on the incidence of T-cell lymphoma from one of the major immunosuppressants, for instance. It’s not easily available, but you can dig for it, and we tackle that in the next chapter. But it’s clear that thousands of ordinary people who were prescribed a drug for a bothersome ailment like psoriasis or a more debilitating ailment like Crohn’s disease are now fighting for their lives after developing T-cell lymphoma or some other potentially fatal complication. The growth of this class of drug—fueled by “new applications” and direct-to-consumers (DTC) TV advertising—is a compounded 14% per year.
One thing is clear: patients taking immunosuppressants on a long- term basis are more likely to die in any one year as a result of suppressing their immune systems than the general population. We just don’t know how much more likely. That information isn’t publicly available because the manufacturers have little incentive to do extensive research on long- term effects. Hopefully the information provided in the next chapter will give you reason to look carefully into any drug that suppresses your immune system.
There are many more examples of overdiagnosis and overtreatment through aggressive protocols, such as the tests for osteoporosis and treat- ment for marginal liver enzyme abnormalities.
The bottom line is this: if a doctor tells you, as a result of testing, that you need to go on a medication indefinitely (in other words, become a permanent patient), stop the train, get off, and read up on your specific condition, its relative risk to you, and the risk/benefit ratio. You have to decide what you want your physical life to look like when you are seventy. Unfortunately, you and your doctor can’t depend on today’s aggressive protocols and profit-driven medications to promote your best interest.
The Facts
- Sixty percent of all Americans over fifty are now described as having a chronic condition and are on long-term medications.
- Millions are being medicated because of borderline test numbers with unknown risk/benefit ratios, as our chapter has demonstrated.
- This epidemic of overtreatment grows yearly as disease is redefined by guideline makers in conjunction with pharmaceutical influences.
- The most prevalent and egregious overtreatment occurs with cases of borderline high blood sugar, borderline high blood pressure, and alleged high cholesterol.
The Path of Wisdom
- Consider not treating your borderline high blood pressure with drugs. Start with lifestyle changes.
- Consider not treating borderline type 2 diabetes without first looking for lifestyle and dietary changes that will help.
- Consider not starting blood thinners for indefinite use. Find a way to address the underlying condition if you can.
- Consider not starting immunosuppressants for indefinite use if you and your doctor can agree on any other alternatives for treatment.
- Set a goal to live the kind of lifestyle that allows you to skip ongoing use of drugs for as long as you can.