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Dr. H. Gilbert Welch | G Force

A healthy dose of skepticism

(Mark Washburn/Dartmouth College)
February 7, 2011

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Q. You say the point of your book is that people should be more skeptical about the value of early detection in medicine. If we look for things to be wrong, we’ll find them, even if we didn’t need to?

A. The problem is that we all harbor abnormalities. People have the abnormality, but [in many cases] the abnormality is never destined to go on to cause symptoms or to cause death. We don’t know which people those are, but we tend to treat everybody.

Q. Our assumption that earlier diagnosis is better isn’t always true, then?

A. The problem is the earlier and earlier you try and get things, the more and more people you [diagnose with disease] who are normal.

Q. What’s the downside of over-treatment?

A. Some people are being treated who can’t possibly benefit because there’s nothing to fix. But they can be hurt. All our treatments have some harms. They range from the nuisance effects of having to fill [prescriptions] and make appointments to physical harms — side effects of drugs, complications of surgery, and even death. For sick people, the harms of our therapy pale by comparison to the benefits, or at least the potential benefits. But for the well it’s a much closer call.

Q. What do you say to people who say they’d rather get the test — they’d rather be safe than sorry?

A. It’s not as clear what the safest strategy is as people might assume.

Q. Will technology save us from this problem? Will we soon figure out how to distinguish dangerous cancers from harmless ones, for instance?

A. I’m not as optimistic as a lot of people. We will get better, but we’ll never have perfect information. We’ll always have this fundamental problem that when we try to get ahead of disease, we’re at risk to tell some people they are diseased who do not need to be told that.

Q. You suggest that younger women at least consider the risk of overdiagnosis before getting annual mammograms. What about a woman who feels a new lump in her breast — should she get a mammogram?

A. If a woman feels a new breast lump, she should come in to see her doctor — that’s not screening, that’s diagnosing.

Q. Is your concern about overdiagnosis really a concern that we’re spending too much money on health care in this country?

A. Yes, it does cost money, but I think even if you have all the money in the world you ought to care about this.

Q. You also talk in the book about diabetes, high blood pressure, high cholesterol, and osteoporosis, where our definition of disease — the numbers that distinguish between who is considered healthy and who is sick — has been substantially lowered in recent years.

A. That’s very concerning because it’s beginning to identify a much lower risk group as being abnormal. They have much less opportunity to benefit [from treatment], because their risk of bad outcomes is relatively low anyway. But they face the same risks of harm, in some cases elevated risk of harm, because it’s easy to make a blood pressure or a blood sugar too low. We can get too enthusiastic and treat too many people and end up hurting them.

Q. Do you think people should avoid medical care then?

A. I’m a believer in medical care when you’re sick. This is not a call to stay away from your doctor when you’re sick. The question is much more: What’s your relationship with medical care while you’re well?.

KAREN WEINTRAUB

Interview was edited and condensed. Karen Weintraub can be reached at karen@karenweintraub.com.

WHO
Dr. H. Gilbert Welch
WHAT
Coauthor of a new book, “Overdiagnosed: Making People Sick in the Pursuit of Health,’’ and a professor at the Dartmouth Institute for Health Policy and Clinical Practice