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Thu September 26, 2013
Could A Diagnosis Make You Sicker? Dartmouth Examines Overdiagnosis
Researchers at the Dartmouth Institute for Health Policy and Clinical Practice have been at the forefront of research on unnecessary diagnosis and treatment.
The problem is big, and solving it may require a major change in the way the whole health system treats illness.
Earlier this month, Dartmouth hosted the first ever international conference on preventing overdiagnosis.
Speaking to a crowd of doctors at the Preventing Overdiagnosis conference, Dr. Steven Woloshin began by diagnosing his audience.
"If you’re awake—and some of you appear to be awake—you may actually be suffering from insomnia. And if you’re feeling a little sleepy at this point, I would worry about excessive daytime sleepiness syndrome."
Woloshin is a researcher at the Dartmouth Institute and co-author of a book called Overdiagnosed: Making People Sick in the Pursuit of Health. But even for someone who wrote the book on overdiagnosis, defining the term is a challenge.
"You know, it’s one of those obvious things that it’s hard to pin down. You know it when you see it."
One person who’s seen overdiagnosis up close is Johanna Trimble, a patient advocate from Canada. She says too much medication almost killed her mother-in law.
"My mother-in-law was on nine drugs. And we were told when we had a medication review with the staff of the residential care home that that wasn’t very many."
Dr. Lisa Schwartz, a Dartmouth professor and co-author of Overdiagnosed says, "unfortunately, everything we do in medicine can both help and hurt."
Schwartz says there are two kinds of overdiagnosis: One is what she calls “medicalizing life”—diagnosing ordinary experiences as diseases; the other is when doctors elevate risk factors that are likely to remain minor into something far more serious.
"So low bone density becomes osteopenia, or borderline high blood sugar is prediabetes."
Another example, is thyroid cancer. Out of 1000 thyroid ultrasounds, 670 will turn up a suspicious abnormality—but less than one of those will turn out to be a dangerous cancer.
In cases like this, says Schwartz, tests and treatment can be more dangerous than the supposed disease. Biopsies can lead to bleeding and infection. Drugs can interact, or produce harmful side effects. The very fact of knowing about relatively innocuous health abnormalities can cause patients debilitating stress. And then there’s the macro problem.
"The Dartmouth Atlas data suggests that as much as 30 percent of health care is waste," says Ellen Meara, a Dartmouth health economist. She says it’s hard to put a dollar amount to the total cost of overdiagnosis, but it’s a big reason why healthcare is so expensive.
And as for what’s driving the problem? Meara says: follow the money.
"As a healthcare provider, you’re paid much more to deliver procedures than you are to educate your patients about why they may not need that procedure."
There are other interests at play, too. Drug companies and device manufacturers seek to expand their markets by expanding disease definitions. Malpractice suits are most often for failure to diagnose—not for unnecessary treatment. And, says Meara, many doctors are simply trying to do all they can to catch a disease early.
"So if you have a patient standing in front of you who wants to know what’s wrong with them, or somebody’s concerned about missing a diagnosis, you’re thinking, look, this is in my patient’s interest. They want more information, not less information."
All that means reducing overdiagnosis won’t be easy. Lisa Schwartz and other Dartmouth doctors say the whole health care system needs to focus more on outcomes, and folks need to start asking when a diagnosis is really necessary.
"We have lots of quality measures in medicine. But all of them typically measure whether you do something. They never measure whether you do too much to somebody."
So next time you go for a physical, she says, think about asking your doctor if you might be at risk for overdiagnosis.