Early diagnosis isn’t always a good thing
If an ounce of prevention is worth a pound of cure, then surely the earlier a disease is diagnosed and treated, the better, right?
Not always, it turns out. A lot depends upon the condition and the treatments being proposed for it.
In this very insightful and engaging book, the authors (all doctors) have succeeded in presenting to the layperson the quandary faced by patients and their physicians in trying to decide how aggressively to diagnose and treat disease at its earliest stages without causing more harm than good.
This is not always clear-cut for many reasons, including the rapid advances in diagnostic techniques that have outpaced the understanding of how certain diseases in their earliest stages do (or do not) progress; the legal system that punishes physicians for “doing too little’’ but never for “being thorough’’ (read: doing too much); and the lobbying and public campaigning in support of mass screening for certain conditions by groups with an interest in increasing the numbers of those diagnosed.
Because of this, more people wind up undergoing tests with inconclusive results. They are diagnosed with conditions and preconditions of unclear significance and with certain early-stage cancers that may or may not develop into actual disease. This, in turn, leads to side effects, pain, and disability from treatments and surgeries that may not have been needed in the first place, and to more money and resources being poured into the maw of the health-care system without any benefit being yielded.
The introduction states that “this book examines the possibility that American medicine now labels too many of us as ‘sick,’ ’’ and in doing so, reaches some very important conclusions about the risks and dangers of overdiagnosis. Even though the book is replete with charts and graphs and relies upon the reader understanding how medical trials are conducted, how to interpret their results, and concepts such as bias and “pre-test probability,’’ these are explained simply and straightforwardly and are easily grasped.
This accessible and important book will help the reader understand the limitations of modern medicine and the perils inherent in an overzealous pursuit of a disease-free existence at any cost. It is also especially timely in raising one of the many issues surrounding the health-care debate. At a time of rising national debt and continued increases in health-care expenditures, there is an urgent need for a careful assessment of the cost-benefit ratio of diagnostic and screening tests.
Such an assessment cannot be made solely by physicians, any more than it can be by the government alone, as the recent debate over “death panels’’ has made clear. It must include representatives from the legal field, academia, clergy, and lay people, so that the decisions reached will represent a societal consensus, and allow physicians to avoid ordering superfluous tests without fear of being sued for malpractice.
In Samuel Shem’s “House of God,’’ written over 30 years ago and set in a large city hospital, one of the senior residents lays out the laws that will help the new interns survive their transition from medical student to doctor with their sanity intact. One of these, “if you don’t take a temperature, you can’t find a fever,’’ is right in keeping with the theme of this book. More is not always better, and sometimes the best thing a doctor can do is to do absolutely nothing at all.
Dennis Rosen, a pediatric lung and sleep specialist at Children’s Hospital Boston, can be reached at firstname.lastname@example.org.