The New York Times has an interesting essay this morning titled “What’s Making Us Sick Is an Epidemic of Diagnoses”. Their point is that medical science has progressed to the point where every little malady, major or minor, is some form of disease to be diagnosed. Can’t sleep? You have a sleep disorder. Are you sad? You have depression. You cough after excercising? You have asthema. Admittedly, this desire to name every malady could be harmless… but it has also become a means to an end… the end being selling you medicines or giving you treatments to address the problem. Of course, when we treat the problem, we create side effects, which create more problems, which we treat, which… you get the picture.
The article postulates many reasons for this happening. Quoting the article:
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 cancer patient.
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 last 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.
I personally think there is an additional factor. Just as someone who reviews a document doesn’t think they have done a good job unless they find something to comment upon (c’mon, those of you with red pens like me — you know what I’m saying), doctors don’t feel they have done a good job unless they find something wrong. This is acerbated by insurance companies, who don’t pay for “well doctor” visits (unless you’re a kid) — they need a diagnosis of a problem before they will pay. So doctors feel a need to diagnose, and on paper we become sicker and sicker.
So, the existential question is: Are we actually sicker than previous generations… or do we just have more names for what ails us, and we’re not afraid to use them.
The article notes the effect of all these diagnosis:
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 — 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 overdiagnosis. Thus, the path of least resistance for clinicians is to diagnose liberally — even when we wonder if doing so really helps our patients.
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.
Why does this interest me so? As folks who have been reading my journal know, for a long time I’ve been suffering from headaches. Before I had sinus surgery two years ago, I believed they were cluster headaches, as they were primarily on the right side of my head, and came in bursts. After the surgery, the nature changed to more sinus-like headaches… and they seemed to be more weather related. They are typically a dull pain behind the eyes, or behind an ear. Sometimes they are at the back of the head (a tension headache?). Sometimes they are still on the right side. Sometimes they totally block the ability to work; usually they are just in the annoyance category. I’m typically able to control them with Excedrin, Benedryl, and T3 (Tylenol+Codeine). I have been given some samples of migraine meds (Maxalt), but I haven’t tried them yet. I should also note that hot steamy showers often help, as does (quite surprisingly) driving the van home in LA traffic listening to NPR news.
Why do I mention this here? My problem is one of diagnosis. I’m unsure how I distinguish a true sinus headache (treatable with pain killers plus decongestants) from a migraine headache (treatable with migraine meds) or a tension headache (treatable with painkillers and hot/cold compresses). After all, research is showing that 97% of self-described sinus headaches were actually migraine attacks. There is also research that shows that headaches triggered by weather changes are also migraines. Yet I don’t have many of the migraine symptomology: no auras, no pulsing, no sensitivity to light, no nausea. Further, the migraine med samples all caution that they shouldn’t be taken if the headache isn’t a migraine. Yet my options without the migraine meds are limited (especially when I’m at work and have to drive the van home)… and I’m worried about medication overuse headaches, which further limits my options. So how does one know?
There are times I really wish Progenitorivox was on the market. It’s the drug I need.
