Tag Archives: overdiagnosis

US healthcare: Atul Gawande has some good news

gawande-mcallen-texas-update

Back in June of 2009, when Congress was just beginning to formulate and debate the Affordable Care Act, Atul Gawande wrote an article on the rising (and exorbitant) cost of US health care. He focused on how waste contributes to cost — not just the usual fraud, high prices, and administrative fees, but unnecessary care: Drugs that are not helpful, operations that do not make patients any better, scans and tests that not only have no benefit, but often lead to harm. Waste accounts for a third of health-care spending. More disturbingly, it can cost people their lives.

Gawande used the town of McAllen, Texas to illustrate his case. McAllen had one of the highest costs in the nation for Medicare — twice as high as El Paso, another Texas border town with similar demographics. And it’s not as if patients in McAllen were receiving better care. Compared to El Paso, patient care was similar or worse.

It turned out that many specialists in McAllen had financial stakes in home-health-care agencies, surgery and imaging centers, and the local for-profit hospital. One local doctor told Gawande: “Medicine has become a pig trough here. … We took a wrong turn when doctors stopped being doctors and became businessmen.” Read more

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Reading Notes #1: Health care inequities. Overdiagnosis. The Doctor/Patient Relationship

benefits-harms-annual-mammography-screening

What follows are items I found interesting in magazines I’ve recently read. Normally I would have tweeted these links, but since I was on vacation from Twitter (see My Twitter vacation), I decided to create a type of blog post called Reading Notes (see Blogging and my Twitter vacation).

The bulleted titles below link to the specific item. There’s more detail on the articles I mention under References. OA indicates open access. $ indicates a pay wall. Note that emphasis in quotations has been added by me. Read more

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When health was something we could simply “forget about”

get-well-soon

I came across the following sentence in The Positive Thinkers, a book originally published in 1965. It strikes me as a good example of how the meaning of health has changed. (emphasis added)

Health is ordinarily regarded — when it is “regarded” at all, for ordinarily the point of being healthy is to be able to forget about it — as a means to other things; healthy men are those able to pursue their ends.

Health is hardly something we’re able to forget about today. We live in a culture where it’s commercially profitable to constantly remind us of widespread, proliferating risks. The conscious, highly intentional pursuit of health is a mark of social status for which we expect to be admired and envied. We “regard” it all the time. Read more

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Medical screening, overdiagnosis, and the motives of for-profit hospitals

Image by @spleenal (Nigel Auchterlounie), who blogs at Spleenal
Image by @spleenal (Nigel Auchterlounie), who blogs at Spleenal

[I don’t seem to be able to display that image anymore, but here’s a link to what I’m talking about.]

This superb graphic was created to dramatize what’s happening these days in the UK, where the National Health Service is being ruthlessly privatized. Here in the US, for-profit medicine is so taken-for-granted that we barely notice it. It’s true, we hear a good deal about conflicts of interest involving pharmaceuticals. Doctors get paid — in one way or another — to increase the profits of Big Pharma, a practice that is detrimental to the financial and/or medical interests of their patients. We hear less about scaring healthy patients into using doctors and services that increase hospital profits (also known as fear mongering). So it was nice to see a recent opinion piece in JAMA that discussed precisely this. Read more

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On healthism, the social determinants of health, conformity, & embracing the abnormal: (4) The abnormal part

Abnormal psychologyContinued from parts one, two, and three.

A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.

How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?

At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.

Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water. Read more

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On healthism, the social determinants of health, conformity, & embracing the abnormal: (3) Connections

Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.

Blog topics and their connections

If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.

Healthism

~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.

“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable. Read more

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On healthism, the social determinants of health, conformity, & embracing the abnormal: (2) Economics & the socio-political

Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.

Blog topics and their connections

The social determinants of health

Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.

The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment. Read more

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On healthism, the social determinants of health, conformity, & embracing the abnormal: (1) Bodies, minds & medicine

It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.

Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.

Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)

Blog topics and their connections

Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are. Read more

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What is healthism? (part two)

Apple and stethoscopeIn part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.

Moral healthism

The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).

This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health. Read more

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What is healthism? (part one)

Apple and stethoscopeThroughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”

In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.

Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.

One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.

This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself. Read more

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Why is it so hard to reduce US health care costs?

Why is it so hard to reduce US health care costsProfessor Victor Fuchs and Dr. Arnold Milstein, both of Stanford University, have an article in a recent issue of The New England Journal of Medicine that asks: Why is it so difficult to reduce health care costs in the US? The article is available in its entirety online, but for those short of time, here’s a concise (and depressing) summary.

The graphic accompanying the article is dramatic in its simplicity. Health care spending in the US is 17% of GDP. In other developed countries (Western Europe, Canada, Australia), the number fluctuates around 10%. And yet life expectancy in the US is the lowest of these countries – almost four years below that of the number one country.

We know that some physicians and health care providers manage to operate at less than 20% of the average cost of care, without sacrificing quality. If everyone followed their example, the US could save $640 billion a year (US health care costs for 2008 were $2.3 trillion). Why doesn’t that happen, or as Fuchs and Milstein put it: “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer comes down to perceptions and behaviors. Read more

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There’s more to life than the pursuit of health

Doctor with stethoscopeA few quotations on attitudes towards the pursuit health:

And do you not hold it disgraceful to require medical aid, unless it be for a wound, or an attack of illness incidental to the time of year, — to require it, I mean, owing to our laziness, and the life we lead, and to get ourselves so stuffed with humours and wind, like quagmires, so to compel the clever sons of Asclepius to call disease by such names as flatulence and catarrh.

– Plato, The Republic, 380 BC

Yes, we suffer pain, we become ill, we die. But we also hope, laugh, celebrate; we know the joy of caring for one another; often we are healed and we recover by many means. We do not have to pursue the flattening out of human experience. I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living.

– Ivan Illich, Health as One’s Own Responsibility – No, Thank You!, (PDF) 1990

After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.

– Lewis E. Foxhall, M.D., The Tyranny of Health, 1994

Thinking that we can make death, illness, or privation easier to bear by preparing for them day and night is a sure way to poison our lives, to spoil the slightest pleasure by imagining its end.

– Pascal Bruckner, Perpetual Euphoria: On the Duty to Be Happy, 2000

In the past, health was usually understood as the normal state of affairs, and taken for granted as [a] feature of life largely beyond the control of the person or the society. The proliferation of reflexive techniques which promise actually to improve one’s health has transformed the very meaning of the term ‘health’. The advent of such an immense range of popular ‘health-enhancement’ or ‘self-improvement’ techniques has meant that health is now seen more as a positive goal to be achieved rather than the normal state of a person without illness.

– Christopher Ziguras, Self-care: Embodiment, Personal Autonomy and the Shaping of Health Consciousness, 2004 (emphasis in the original)

There have always been individuals willing to point out that the constant pursuit of health is not the be-all-and-end-all of life. This eminently reasonable attitude, however, is increasingly rare among both doctors and patients. We have been educated to believe – primarily by what Ziguras calls “commodified and mediated health advice,” but also by the medical and public health professions – that feeling good and assuming we’re healthy could all too easily be a delusion. How can we be certain some fatal disease doesn’t lurk in the unreliable interior of the body?

We choose to pursue health or to pursue disease

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From healthism to overdiagnosis

H Gilbert Welch OverdiagnosedIn his new book, Overdiagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch enumerates how the cutoff points that determine whether a patient should be treated for a disease – diseases such as high blood pressure, diabetes, osteoporosis — have been creeping inexorably lower over the years.

Take diabetes. The cutoff point used to be a fasting blood sugar level of greater than 140. In 1997, the number was lowered to 126. This immediately created 1.7 million new diabetes patients.

In a highly publicized study that began in 2003, one group of patients with type 2 diabetes received “intensive therapy” to make their blood sugar “normal.” The control group – the other half of over 10,000 patients – received treatment to lower their blood sugar, but not to the new normal level. The trial was stopped in 2008 when it became clear that there was about a 25% increased risk of dying for the intensive therapy group.

Dr. Welch’s comment on this: “If it’s not good to make diabetics have near normal blood sugars, then it’s not good to label those with near normal blood sugar diabetics. Why? Because doctors will treat them. People with mild blood sugar elevations are the least likely to gain from treatment – and arguably the most likely to be harmed.”

High blood pressure (hypertension) was also redefined in 1997. Instead of the cutoff points being 160 systolic over 100 diastolic, the numbers dropped to 140 over 90. This created 13.5 million new patients.

The definition of high cholesterol (hyperlipidemia) changed following a 1998 clinical trial. The definition of “abnormal” total cholesterol fell from 240 to 200. This created 42.6 million new patients, an increase of 86% over the previous number of patients.

It’s the same with the definition of osteoporosis. A bone mineral density X-ray produces a T score. It’s a way to compare an individual’s bone density to what’s considered “normal.” For women, normal is defined as the bone density of an average white woman aged 20 to 29 (a T score of zero.) If your T score is less than zero, it’s assumed you have an increased risk of fracture.

In 2003 the definition of osteoporosis changed from having a T score less than -2.5 to less than -2.0 (i.e., closer to normal). This created 6.8 million new patients, an 85% increase in those now eligible for treatment with drugs that turned out to have significant side effects – as virtually all drugs do. Read more

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Are the most heavily marketed drugs the least beneficial?

Prescription drugs symbolIn a perfect world, doctors would not prescribe – and patients would not take – drugs that do more harm than good. But it’s complicated. The benefits and harms of drugs are determined in randomized, controlled clinical trials. For many reasons, the outcomes of such trials may not provide doctors with the information they need to decide who should take what.

For example, harmful effects (like death) may not show up during the limited time span of a trial. Data from trials may be selected – and other data ignored — to produce positive results. This is apt to happen when clinical trials are conducted by the pharmaceutical industry, rather than by economically disinterested parties, such as the NIH or independent academic institutions. Also, the participants in the trial may differ significantly (in age, gender, and health, e.g.) from patients who end up taking the drugs. As a recent article in JAMA put it, “most clinical trials fail to provide the evidence needed to inform medical decision making.”

The Inverse Benefit Law

If you follow pharma news, you will have noticed that many high profile, aggressively marketed drugs turn out to be either ineffective or positively dangerous (think Vioxx, widely prescribed for arthritis, which turned out to cause heart attacks and stroke). Howard Brody, MD, and Donald Light, PhD, have proposed an explanation for this phenomenon. They call it the Inverse Benefit Law: “The ratio of benefits to harms among patients taking new drugs tends to vary inversely with how extensively the drugs are marketed.” Or (for those who feel fuzzy about inversion): The more aggressively a drug is marketed, the more likely the drug will cause harm, be ineffective, or deliver little by way of benefit. Read more

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Robots dispense drugs and remove prostates

UCSF robot pharmacyEric Schmidt, chairman of Google, speaks of the “age of augmented humanity.” If we let computers do the things they do well, this will free up humans to be better at the things they do well. “The computer and the human each does something better because the other is helping.”

A win-win use of automation appears to be dispensing drugs in hospitals. The University of California, San Francisco (UCSF) has a team of robots that fills prescriptions for its medical center. Orders are submitted electronically. The drugs are retrieved from a secure, sterile environment. The dosage is as exact as a computer is logical. Medications are packaged for each patient – even assembled into 12-hour packets for the day. This eliminates possible errors by both pharmacists and nurses.

According to UCSF:

By using robots instead of people for previous manual tasks, pharmacists and nurses will have more time to work with physicians to determine the best drug therapy for a patient, and to monitor patients for clinical response and adverse drug reactions.

The dean of UCSF’s School of Pharmacy concurs:

The beauty of this robotic pharmacy system is that the pharmacist is taken out of that mechanical aspect of pharmacy practice, and they can use their intellect to be sure that the patients at the bedside are getting absolutely the right medicine.

It’s sort of like using scanners to buy groceries or to check out books at the library. It may put some people out of work, but hey. That’s the price we pay for the age of augmented humanity.

This video of the robots in action is actually quite good. Read more

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The duty to be happy

Pascal Bbruckner Perpetual EuphoriaThe French intellectual Pascal Bruckner casts a critical eye on happiness in his newly translated book, Perpetual Euphoria: On the Duty to Be Happy. Much of what he has to say about happiness applies equally to health.

In the first post on this blog I asked: How did health, which used to be something we were born with, become something we believe we can personally control. Today most people in developed countries assume they can avoid certain diseases and prolong their lives by practicing a “healthy lifestyle.” How did this happen? When did the change occur? What does it mean that – unlike earlier generations — we’re so preoccupied with our health?

Attitudes towards both health and happiness changed in the sixties. In an interview in The Guardian, Bruckner comments: (emphasis added)

After the 60s, there is no more distance between one’s happiness and oneself. … One becomes one’s own main obstacle. To overcome this obstacle a huge market opened: medicine to modify your mood, surgery to modify your body, and it also includes the spread of therapy and new or reformed religions. So Jesus is no longer this transcendent God, but a life coach who helps you overcome addiction and so on. …

We should wonder why depression has become a disease. It is a disease of a society that is looking desperately for happiness, which we cannot catch. And so people collapse into themselves. …

[P]eople are very unhappy when they try hard and fail. We have a lot of power in our lives but not the power to be happy. Happiness is more like a moment of grace.

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Links: Dogs help children read/Becoming an MD/Overdiagnosis/Misdiagnosis/Patient modesty/An MD’s compassion

Listening dog helps children readThe dogs who listen to children reading (Guardian)
“Listening dog” encourages children to read aloud. “It helps with their self-esteem in reading out loud because he is non-judgmental. He doesn’t judge them and he doesn’t laugh at them.” Greyhounds are the dog of choice. Adopt a greyhound website.

18 Stethoscopes, 1 Heart Murmur and Many Missed Connections (NYT)
A woman (journalist/author) with a clearly audible mitral valve click volunteers to let second year med students listen. Interesting observations on doctor/patient relationship, learning to be a doctor.

Prostate Guideline Causes Many Needless Biopsies, Study Says (NYT)
Support for H. Gilbert Welch’s contention in Overdiagnosed. Turns out medical guideline on P.S.A. velocity (the rate of change in readings from year to year) is not associated with disease, as previously assumed.

100,000 NHS patients given wrong diabetes diagnosis, says report (Guardian)
50,000 people told they had diabetes when they did not. A similar number misdiagnosed with Type 1 when they had Type 2 and vice versa. Errors due to mistakes by medical staff and lack of understanding of the condition by doctors. Read more

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Links: Birthing your own grandchild/Welch’s Overdiagnosis/Al Qaeda/Cats/Polar bears

Woman gives birth to own grandchild61-year-old woman gives birth to her own grandchild, and so what? (Practical Ethics)
The news is that it’s not news. Euthanasia, divorce, same sex marriage, in vitro fertilization — the common perception of these practices has changed radically in the last 30 years. Comments from Italian bioethicist.

Creeping sickness: Our epidemic of diagnosis (New Scientist)
Review of H. Gilbert Welch’s new book, Overdiagnosed: Making People Sick in the Pursuit of Health. (Just got my copy) Today people have pre-diseases: pre-diabetes, pre-hypertension, pre-hyperlipidemia, pre-osteoporosis. Healthy people with no symptoms are urged to seek treatment.

Overdiagnosis and the dangers of early detection (BMJ)
Ray Moynihan reviews H. Gilbert Welch’s new book. Overdiagnosis is one of medicine’s biggest problems, causing millions of people to become patients unnecessarily, producing untold harm, and wasting vast amounts of resources. Many of the big and costly medical conditions of our time are not in fact diseases, but rather are risk factors portrayed as diseases. “These decisions [about the definition of a disease and guidelines of its treatment] affect too many people to let them be tainted by the businesses that stand to gain from them.”

Cats Adore, Manipulate Women (Discovery)
Cats attach to humans, particularly women, as social partners, not just for the sake of obtaining food. They hold some control over when they are fed and handled, functioning very similar to human children in some households. “A relationship between a cat and a human can involve mutual attraction, personality compatibility, ease of interaction, play, affection and social support. A human and a cat can mutually develop complex ritualized interactions that show substantial mutual understanding of each other’s inclinations and preferences.” I can so relate to that. Read more

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A doomed and dysfunctional medical culture

Newborn babyJ.D. Kleinke is a medical economist, health information industry pioneer, and author of the forthcoming Catching Babies. In a dramatic, powerful, and beautifully written post on The Health Care Blog, he captures the essence of what’s wrong with modern medicine.

Kleinke tells the story of Hannah, a family member. She is 39 weeks pregnant (a typical pregnancy is 38 weeks) and has been losing weight. Her baby is small, at the 7th percentile for fetal weight.

Hannah could be experiencing something called intrauterine growth restriction. If she is – and if she continues the pregnancy – her baby could suffer developmental delay and retardation. On the other hand, if she allows the hospital to induce labor, she could end up with a c-section and the numerous complications that often follow this procedure. “The blessing and the curse of modern medicine,” Kleinke writes, “from the NICU to the oncology unit, is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.”

Medicalization, patient preference, and provider prejudice

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The downside of overly aggressive cancer screening

False positive mammogramOne more follow-up on overly aggressive cancer screening (see Screening for cancer and overdiagnosis and Creating an epidemic of cancer among the healthy). A recent study found that false-positive results of breast cancer screening create anxiety and undermine the patient’s quality of life for up to a year.

Here’s an excerpt from BusinessWeek:

“Common sense tells us that early detection of breast cancer is good, and most screening programs have been successful in reducing breast cancer deaths,” lead author Dr. Lideke van der Steeg, of the department of surgery at St. Elisabeth Hospital in Tilburg, said in a journal news release.

“However, while some women truly benefit from early detection, others experience harm and unnecessary anxiety. The women who received false-positives in our study experienced a significant reduction in their quality of life, especially if they were prone to anxiety, and the effects of this lasted at least a year.”

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Creating an epidemic of cancer among the healthy

Siddhartha Mukherjee Tthe emperor of all maladiesFollowing up on Dr. H. Gilbert Welch’s comments on the new blood test for cancer – that overdiagnosis may lead to an epidemic of individuals who mistakenly believe they have cancer – here’s a description of the climate that’s created when we try to scare people into believing they have cancer. It’s from a review of The Emperor of All Maladies, a new book on the history of cancer by Siddhartha Mukherjee.

Writing in The New Yorker, the author of the article, Steve Shapin, explains optimism surrounding the drug Gleevec, a new type of cancer drug that targets a known cancer gene. Gleevec has been quite successful in the treatment of leukemia. (emphasis added) Read more

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Screening for cancer and overdiagnosis

Screening for cancer: OverdiagnosisEarlier this month scientists announced a test that can detect a single cancer cell in a blood sample. Although some news reports were realistic – BusinessWeek commented that “researchers still aren’t sure what these circulating tumor cells (CTCs) actually mean” – most greeted the news as a revolution in the fight against cancer, promising early, non-invasive detection.

Dr. H Gilbert Welch offered a more sober opinion. Welch is the author of Should I Be Tested for Cancer?: Maybe Not and Here’s Why. While it’s commonly assumed that screening saves lives and that more screening is always better, Welch’s book helps patients (and the medical profession) understand that the implications of cancer screening are more complex.

More medical care leads to more screening

As Welch points out, medical care is a much more prominent part of our lives today than it was in the past. There are a number of reasons for this. Read more

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Misc Links 1/19/11

Blood test for cancer -- breakthrough or nightmareCancer breakthrough — or nightmare? (CNN)
A simple blood test that detects minute quantities of cancer cells in the blood “could just as easily start a cancer epidemic. … The conventional wisdom is people either have a disease or they do not. But, in fact, there are a lot of people somewhere in between.” H. Gilbert Welch on overdiagnosis.

Intelligence and physical attractiveness (Science Direct)
If women prefer intelligent men because they have higher incomes and status, and if men prefer physically attractive females, eventually the two traits merge. Study finds physically attractive people are more intelligent.

Programmed for Love (Chronicle)
New Sherry Turkle book “Alone Together.” The growing trend in robotics to create machines that act as if they’re alive could lead us to place machines in roles that only humans should fill. Plus effects of social media on young people. “Although always connected, they feel deprived of attention.”

BMJ Blasts Lancet Role in MMR-Autism Scare (MedPage Today)
Brian Deer and the Lancet have at each other, tabloid style. Takeaway: There should be new procedures for enforcing ethical standards of medical research. Read more

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Mental illness in college students: Overdiagnosed

Mental health college students overdiagnosisThe New York Times ran an article in December about the declining mental health of college students. The focus of the article was actually on how difficult it is for understaffed counseling centers to cope, but the problem was framed with some disturbing statistics: “44 percent [of students] in counseling have severe psychological disorders, up from 16 percent in 2000, and 24 percent are on psychiatric medication, up from 17 percent a decade ago.”

The article offered two possible explanations for these statistics: More students are able to attend college because effective psychiatric medicine is available and/or counselors are now better at recognizing a serious illness than they used to be.

Experts say the trend is partly linked to effective psychotropic drugs (Wellbutrin for depression, Adderall for attention disorder, Abilify for bipolar disorder) that have allowed students to attend college who otherwise might not have functioned in a campus setting.

There is also greater awareness of traumas scarcely recognized a generation ago and a willingness to seek help for those problems, including bulimia, self-cutting and childhood sexual abuse.

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Misc Links 1/14/11

Chinese mother with musically gifted childrenWhy Chinese Mothers Are Superior (WSJ)
“What Chinese parents understand is that nothing is fun until you’re good at it. To get good at anything you have to work, and children on their own never want to work, which is why it is crucial to override their preferences.”

Is Extreme Parenting Effective (NYT)
Response to WSJ article on superiority of strict Chinese mother parenting style. Does strict control of a child’s life lead to greater success or can it be counterproductive?

Are College Students Getting Sicker? No, Diagnoses Change Faster Than People (Psychiatric Times)
The sudden exploding rate of “severe” psychiatric illness on campus is most likely caused by overdiagnosis, not by a decline in the mental health of the college students.

A Tale of Two Moralities (NYT)
Paul Krugman: There is a deep divide in American political morality, between those who believe a wealthy nation should provide essential health care for all and those who believe such reform is a moral outrage. Read more

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Should grief be labeled and treated as depression?

GrievingThe American Psychiatric Association (APA) is in the process of revising the Diagnostic and Statistical Manual of Mental Disorders (DSM) – the psychiatrist’s bible. Its last incarnation — known as DSM IV — was published in 2000. The new version will be DSM V. … One item in dispute is whether bereavement – the grieving process that follows the loss of a loved one – might qualify a patient for the DSM label Major Depressive Episode. Read more

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