Diagnosis Epidemic: A Major Health Threat
By H.Gilbert Welch, Lisa Schwartz and Steven Woloshin
(What's Making Us Sick Is An Epidemic Of Diagnoses) The New York Times 1/10/07
For most Americans, the biggest health threat is not avian flu, West Nile or mad
cow disease. It's our health-care system. Americans live longer than ever, yet
more of us are told we are sick. How can this be? One reason is that we devote
more resources to medical care than any other country. Some of this investment
is productive, curing disease and alleviating suffering. But it also leads to
more diagnoses, a trend that has become an epidemic.
This epidemic is a threat to your health. It has two distinct sources. One is
the medicalization of everyday life. Most of us experience physical or
emotional sensations we don't like, and in the past, this was considered a part
of life. Increasingly, however, such sensations are considered symptoms of
Everyday experiences like insomnia, sadness, twitchy legs and impaired sex drive
now become diagnoses: sleep disorder, depression, restless leg syndrome and
Perhaps most worrisome is the medicalization of childhood. If children cough
after exercising, they have asthma; if they have trouble reading, they are
dyslexic; if they are unhappy, they are depressed; and if they alternate
between unhappiness and liveliness, they have bipolar disorder. While these
diagnoses may benefit the few with severe symptoms, one has to wonder about the
effect on the many whose symptoms are mild, intermittent or transient. The other source is the drive to find disease early.
While diagnoses used to be reserved for serious illness, we now diagnose illness
in people who have no symptoms at all, those with so-called predisease or those
Two developments accelerate this process. First, advanced technology allows
doctors to look really hard for things to be wrong. We can detect trace
molecules in the blood. We can direct fiber-optic devices into every orifice.
And CT scans, ultrasounds, M.R.I. and PET scans let doctors define subtle
structural defects deep inside the body. These technologies make it possible to
give a diagnosis to just about everybody: arthritis in people without joint
pain, stomach damage in people without heartburn and prostate cancer in over a
million people who, but for testing, would have lived as long without being a
Second, the rules are changing. Expert panels constantly expand what constitutes
disease: thresholds for diagnosing diabetes, hypertension, osteoporosis and
obesity have all fallen in the past few years. The criterion for normal
cholesterol has dropped multiple times. With these changes, disease can now be
diagnosed in more than half the population.
Most of us assume that all this additional diagnosis can only be beneficial. And
some of it is. But at the extreme, the logic of early detection is absurd. If
more than half of us are sick, what does it mean to be normal? Many more of us
harbor "pre-disease" than will ever get disease, and all of us are "at risk."
The medicalization of everyday life is no less problematic. Exactly what are we
doing to our children when 40 percent of summer campers are on one or more
chronic prescription medications?
No one should take the process of making people into patients lightly. There are
real drawbacks. Simply labeling people as diseased can make them feel anxious
and vulnerable &emdash; a particular concern in children. But the real problem with the epidemic
of diagnoses is that it leads to an epidemic of treatments. Not all treatments
have important benefits, but almost all can have harms. Sometimes the harms are
known, but often the harms of new therapies take years to emerge &emdash; after many have been exposed. For the severely ill, these harms
generally pale relative to the potential benefits. But for those experiencing
mild symptoms, the harms become much more relevant. And for the many labeled as
having predisease or as being "at risk" but destined to remain healthy,
treatment can only cause harm.
The epidemic of diagnoses has many causes. More diagnoses mean more money for
drug manufacturers, hospitals, physicians and disease advocacy groups.
Researchers, and even the disease-based organization of the National Institutes
of Health, secure their stature (and financing) by promoting the detection of
"their" disease. Medico-legal concerns also drive the epidemic. While failing
to make a diagnosis can result in lawsuits, there are no corresponding
penalties for over diagnosis. Thus, the path of least resistance for clinicians
is to diagnose liberally - even when we wonder if doing so really helps our
As more of us are being told we are sick, fewer of us are being told we are
well. People need to think hard about the benefits and risks of increased
diagnosis: the fundamental question they face is whether or not to become a
patient. And doctors need to remember the value of reassuring people that they
are not sick. Perhaps someone should start monitoring a new health metric: the
proportion of the population not requiring medical care. And the National
Institutes of Health could propose a new goal for medical researchers: reduce
the need for medical services, not increase it.
Dr. Welch is the author of "Should I Be Tested for Cancer? Maybe Not and Here's
Why" (University of California Press). Dr. Schwartz and Dr. Woloshin are senior
research associates at the VA Outcomes Group in White River Junction,Vt.