Is eliminating the presence of all disease a worthy goal?
Gilbert Welch is part of the Dartmouth group of physicians and policy experts who advocate that we’re doing too much testing and finding too many diseases. He asks, what exactly does “health” mean, and should it be defined as the absence of disease?
Over time, the definition of “normal” has narrowed. For instance, more patients are being diagnosed with hypertension or hyperlipidemia, simply by moving the goalposts of what “normal” means. The result? More people are being treated for a variety of conditions, either through drugs or undergoing procedures, and because of this, “it has been a disaster for health-care costs.”
Worse, striving for complete absence of disease has led to other, widespread repercussions:
Doctors who are overwhelmed by the number of ailments their patients allegedly have (and who are often distracted from the most important ones); doctors in training who are increasingly confused about who is really sick and who is not; lawyers who increasingly have a field day with the charge of “failure to diagnose”; patients who get too much treatment or lose health insurance because they been given a new diagnosis; and a frazzled, fearful public adrift in a culture of disease.
We need to redefine the goals of our health, and stop striving for perfection.
Or, as Dr. Welch puts it, “you have to take back responsibility for deciding what health really means, not surrender that decision to ‘experts’ with strong financial incentives.”
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{ 7 comments }
I agree that imaging studies are finding a lot “incidentalomas” that often necessitate further workup, driving up costs, as well as morbidity and mortality.
However, I disagree with their chosen examples of hypertension, hyperlipidemia, and diabetes. There are clear benefits to treating hypertension to the goal of < 140/90 (or 125 remains the diagnostic criteria. This cutoff was taken from classic studies that determined at which point end-organ damage was first appearing. I think it’s a good idea to identify people with “pre-diabetes” or impaired fasting glucose, as this is the group which can benefit most from therapeutic lifestyle change (diet and exercise) to avoid getting frank DM2.
So for these disease entities, I don’t think that the “medical-industrial complex” is trying to find more ways to label people, but rather to identify those in whom you can intervene early. It’s the diagnoses of restless leg syndrome, adult ADHD, “bulging discs” that I doubt.
“Normal” and “healthy” are not the same thing, though. In the US, it is “normal” for people aged 45-64 to be on some sort of drugs for chronic conditions (I read a post in some forum where a 55 year old man wrote that he surprised doctors and nurses simply by telling them that he was taking no medication).
Of course, some of these chronic conditions for which people take medication are due to poor health habits. It is “normal” for adults in the US to be overfat. It is “normal” in the US to eat a lot of junk food while not eating much vegetables. It is “normal” in the US to not exercise very much, even to the point of actively avoiding exercise (e.g. waiting for a crowded or slow escalator or elevator instead of walking up the stairs).
This article seems totally wrong-headed. A better question to ask is, “should people strive for optimal health?”
Yes, they should. It will involve high levels of fitness as a main goal.
What should the doctor’s role be? The article presupposes that doctors goals are to diagnose and treat “sickness”, and to test for results that are within “normal” ranges. However, if their goal were to help people achieve optimal health instead, then they could give their patients feedback and advice instead of merely diagnosing illness. For example, develop some basic fitness tests and encourage them to get physically fit. Help them avoid illness by encouraging them to take care of themselves. Instead of providing treatment for early stages, put it in the patient’s hands: you will develop heart disease if you don’t bring your cholesterol down – here is what you need to do (without statins, etc).
Lowering the bar on what “health” means is not the solution – raising the bar on patient responsibility for their own health is. More testing is better, because it can provide feedback and guide patient lifestyle choices.
Brent has it with this sentence:
“Lowering the bar on what “health” means is not the solution – raising the bar on patient responsibility for their own health is.”
One thing about incidentalomas – an abnormal finding on imaging done for another purpose – they do not necessarily “require” further workup, in the sense that a patient has no other option. Risks vs. benefit for further testing needs to be relayed accurately and reasonable guidance given. Patients can certainly be told the truth about any finding, and follow the treatment course most suited to their individual, unique situations.
As a hospitalist, I have discovered that 85-95% (depending on time of year) of the people I treat have low levels of Vitamin D. I have also discovered that by screening and using cholecalciferol (that’s cholecalciferol, people, or Vitamin D3 to you Walmart shoppers) liberally I shorten length of stay and effect quick (occasionally amazing) clinical turnaround in autoimmune disease, decubs, cardiomyopathy, encephalopathy and a wide range of other illnesses not (yet) robustly linked to Vitamin D levels. I am told by other hospitalists that this is not my job. My job is said to be to make people “less sick” enough to go home (not apparently to try to keep them from becoming repeat customers). Modern medicine, you reek.
I think more patients should be given an OPTION. Tell them that nothing HAS to be treated. Patients are sentient beings who can make decisions for themselves. If you don’t want to talk 32 pills a day, then don’t. You will have consequences X, Y and Z, but at least you won’t have side effects A, B and C. It’s your decision.
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