nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Tuesday, January 25, 2011

BOOK: "Overdiagnosed" Generalizes Too Much--And Another Personal Story

 
A new book called "Overdiagnosed" got me to thinking about treating health issues when the patient feels well.

The authors make a point about looking for diagnoses when there are no symptoms, and someone feels healthy.  Most doctors would agree that if you do enough lab tests, you'll find an abnormal value that's a red herring.

But this is different.  The authors, of "Overdiagnosed," H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin, make their point in this way:
"Overdiagnosis occurs when physicians make a diagnosis in an individual who would never go on to develop symptoms or die from the condition. It happens when we try to make diagnoses too early, in people who don’t have symptoms. I’m not saying we should never do that, but members of the general public have gotten the message that early diagnosis is always in your best interest, that it’s always good to look harder and find more. But the reality now is that we can find abnormalities in just about everyone and that can start a whole train of harmful events. So we all need to adopt a more balanced approach."  (WSJ Health Blog, Jan 20)
Problems:
1.  Often people have no symptoms when a serious illness is in its early stages.  Breast cancer, borderline heart failure, diabetes, and the like.  There are standards for when people are most prone to develop certain serious problems, and screening tests are used to discover them.  There aint no such thing as "too early" a diagnosis here.

2.  There's some research that says better control of some borderline conditions improves the long-term prognosis.  Welch and his co-authors give the example of borderline high blood pressure (hypertension) as an overdiagnosis.  However, we have some data to show that if you control borderline hypertension, or get even better control of some one who already is under treatment for hypertension, you reduce the risk of heart attack and stroke further.

Here's a personal story  (my other personal stories are here and here).  I have hypertension.  It's not that bad.  At first, 6 years ago, I would have a borderline reading at the doctor's office; but not always.  So, I asked for a 24-hour blood pressure (BP) monitoring.  It showed that while my BP didn't often get high (while resting) during the day, at night there wasn't the normal fall in pressure that occurs with sleep.  This is a sign of developing hypertension.

For me, this was enough.  I was having trouble exercising to control BP and weight, due to back problems.  I knew that the damage from high BP comes from many years of being high, during which I would feel fine (no symptoms).  But after 20 years of this, there will be risks: heart attack, stroke, kidney damage, vascular trauma, circulation issues, etc. 

So, I went on medication.  It brought down the pressure, but not to what it was when I was 20 years old.  For example, if without treatment I averaged 145/92, under treatment I would be 135/80.  But back when I was younger and running every day, the average was about 118/68.  Initially, my doctor--and I--was happy to get below the 140/90 threshold.

But later, large-scale reviews began to show that if you could normalize the pressure even more, the risk would fall even further.   There's a counter-balancing risk, however; if you over correct, people can get syncopal--their blood pressure can be that low under normal circumstances, but when they stand up quickly, or get a little dehydrated, they can feel faint.

In any case, I asked for more aggressive treatment.  It brought down my BP.  In the meantime, I had back surgery (I posted that personal story, too), allowing more physical exercise.  Admittedly, there were a few times when, working out in the heat of the summer, I got a little woozy and had to sit down for a minute.  So, we re-adjusted the medications.

Having this condition--hypertension--is like having diabetes, you have to monitor things.  Not all the time, but every few months or so.  I lost weight exercising, and my need for medicine went down, so another adjustment was needed.  These days, I range about 128/75, which is safe and probably an improvement over my initial therapy.

But I'm still watching the research on this, because science is always being modified by new results.  Should the benefits of "optimizing" blood pressure, as opposed to "lowering" BP turn out to be minimal, then I'll re-look at the strategy.  That's the way it works.

The authors' example of borderline cholesterol results can be argued similarly.

But unlike my story about getting a spinal fusion, I've tried to avoid being Dr. Know-it-all, and work with my doctor to obtain the best solution.  When I try to run my own medical care, I'm just as stupid (if not more so--a little knowledge is dangerous) as anybody else.  None of the above should be undertaken on your own, and it may be that your condition is not amenable to this kind of management.  Or you may decide, with the authors, that living your life unburdened by early diagnosis is happier.  (BIG DISCLAIMER).

So back to the book "Overdiagnosed."  I can't agree with the underlying premise that accidental health issues, uncovered by routine exam or testing, which are asymptomatic--and the patient is feeling well--should be unexplored.

There are many health issues that benefit from being discovered early.  And, in particular, there are conditions where fully treated borderline, or partially corrected, problems can make a difference to long-term health.

We're all unique.  Generalizing about "over"-diagnosis makes the mistake of "over"-looking that fact.

Doc D
 

2 comments:

WarmSocks said...

Those routine screenings can be very helpful. My cousin had no symptoms yet, but had aplastic anemia diagnosed from tests done for a high school sports physical.

Doc D said...

Good example. I'm convinced you can't treat patients the same way you would fix your car. Someone might argue that in your example it's not cost-effective to do a million physicals to pick up one aplastic anemia...unless it was them. There are no generic patients, only unique individuals.

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