It seems the doctor’s role has changed in the past 50 years. At one time, doctors saw sick people and helped to make them well. They still do that, of course, but now their role has expanded: they see well people and help to make them sick.
That, at least, is the contention of Dartmouth professor of medicine H. Gilbert Welch, who wrote in a short, incisive op-ed piece in the New York Times this week about our obsession with early diagnosis as preventive medicine. He writes, “The basic strategy behind early diagnosis is to encourage the well to get examined — to determine if they are not, in fact, sick. But is looking hard for things to be wrong a good way to promote health? The truth is, the fastest way to get heart disease, autism, glaucoma, diabetes, vascular problems, osteoporosis or cancer … is to be screened for it.”
He continues, “Screening the apparently healthy potentially saves a few lives (although the National Cancer Institute couldn’t find any evidence for this in its recent large studies of prostate and ovarian cancer screening). But it definitely drags many others into the system needlessly — into needless appointments, needless tests, needless drugs and needless operations (not to mention all the accompanying needless insurance forms).
“This process doesn’t promote health; it promotes disease. People suffer from more anxiety about their health, from drug side effects, from complications of surgery. A few die. And remember: these people felt fine when they entered the health care system.”
Welch doesn’t think that early diagnosis is always a bad thing, just that it leads in too many cases to overdiagnosis and overtreatment. I think he’s right, and there are several characteristics of our current medical milieu that will tend to make the problem worse. Consider the following:
1. The World Health Organization’s definition of health is “ a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Under that breathtaking definition, everybody is sick, and every aspect of life comes under the purview of the health care provider. To the degree that we buy into this definition, we feed into the tendency towards “diseasification” of which Welch writes.
2. You ain’t seen nothin’ yet. As genomic sequencing proliferates, we are finding that you don’t have to tunnel very far into one’s DNA to discover that everybody has significant genetic dispositions towards one or more dread diseases. We already see patients worried sick believing that, because they have high cholesterol, they have a disease, when what they really have is a risk factor for a disease. Combine the tendency to equate risk factor with disease, people’s belief that genetic information is somehow more determinative than other types of information, and the messiness of our genes, and even the healthiest among us will have excuse to view themselves as cripples.
There are different kinds of “Preventive medicine.” One is worry-based: I worry about whether I have or might get a disease, I get screened for everything, and I can’t be thankful for the health that I do enjoy because anxiety is my constant companion. The other type involves getting some exercise, eating a reasonable diet, and making time for decent rest. It’s characterized more by thankfulness than worry, and has a better chance of improving our lives: for, as a wise Physician once said, “Can any of you by worrying add a single hour to your life?”