What do you think?
Rate this book
Overdiagnosed: Making People Sick in the Pursuit of Health
An exposé on Big Pharma and the American healthcare system ’s zeal for excessive medical testing , from a nationally recognized expert
More screening doesn’t lead to better health—but can turn healthy people into patients.
Going against the conventional wisdom reinforced by the medical establishment and Big Pharma that more screening is the best preventative medicine, Dr. Gilbert Welch builds a compelling counterargument that what we need are fewer, not more, diagnoses. Documenting the excesses of American medical practice that labels far too many of us as sick, Welch examines the social, ethical, and economic ramifications of a health-care system that unnecessarily diagnoses and treats patients, most of whom will not benefit from treatment, might be harmed by it, and would arguably be better off without screening.
Drawing on 25 years of medical practice and research on the effects of medical testing, Welch explains in a straightforward, jargon-free style how the cutoffs for treating a person with “abnormal” test results have been drastically lowered just when technological advances have allowed us to see more and more “abnormalities,” many of which will pose fewer health complications than the procedures that ostensibly cure them. Citing studies that show that 10% of 2,000 healthy people were found to have had silent strokes, and that well over half of men over age sixty have traces of prostate cancer but no impairment, Welch reveals overdiagnosis to be rampant for numerous conditions and diseases, including diabetes, high cholesterol, osteoporosis, gallstones, abdominal aortic aneuryisms, blood clots, as well as skin, prostate, breast, and lung cancers.
With genetic and prenatal screening now common, patients are being diagnosed not with disease but with “pre-disease” or for being at “high risk” of developing disease. Revealing the economic and medical forces that contribute to overdiagnosis, Welch makes a reasoned call for change that would save us from countless unneeded surgeries, excessive worry, and exorbitant costs, all while maintaining a balanced view of both the potential benefits and harms of diagnosis. Drawing on data, clinical studies, and anecdotes from his own practice, Welch builds a solid, accessible case against the belief that more screening always improves health care.
More screening doesn’t lead to better health—but can turn healthy people into patients.
Going against the conventional wisdom reinforced by the medical establishment and Big Pharma that more screening is the best preventative medicine, Dr. Gilbert Welch builds a compelling counterargument that what we need are fewer, not more, diagnoses. Documenting the excesses of American medical practice that labels far too many of us as sick, Welch examines the social, ethical, and economic ramifications of a health-care system that unnecessarily diagnoses and treats patients, most of whom will not benefit from treatment, might be harmed by it, and would arguably be better off without screening.
Drawing on 25 years of medical practice and research on the effects of medical testing, Welch explains in a straightforward, jargon-free style how the cutoffs for treating a person with “abnormal” test results have been drastically lowered just when technological advances have allowed us to see more and more “abnormalities,” many of which will pose fewer health complications than the procedures that ostensibly cure them. Citing studies that show that 10% of 2,000 healthy people were found to have had silent strokes, and that well over half of men over age sixty have traces of prostate cancer but no impairment, Welch reveals overdiagnosis to be rampant for numerous conditions and diseases, including diabetes, high cholesterol, osteoporosis, gallstones, abdominal aortic aneuryisms, blood clots, as well as skin, prostate, breast, and lung cancers.
With genetic and prenatal screening now common, patients are being diagnosed not with disease but with “pre-disease” or for being at “high risk” of developing disease. Revealing the economic and medical forces that contribute to overdiagnosis, Welch makes a reasoned call for change that would save us from countless unneeded surgeries, excessive worry, and exorbitant costs, all while maintaining a balanced view of both the potential benefits and harms of diagnosis. Drawing on data, clinical studies, and anecdotes from his own practice, Welch builds a solid, accessible case against the belief that more screening always improves health care.
228 pages, Paperback
First published January 1, 2011
185 people are currently reading
4397 people want to read
Ratings & Reviews
Friends & Following
Create a free account to discover what your friends think of this book!
Community Reviews
Displaying 1 - 30 of 220 reviews
July 29, 2012
First-World problems.
If you’ve been led to believe that it’s a good idea to get an annual physical checkup even though there’s nothing wrong with you, you need to read this book. The idea that it’s beneficial that we subject ourselves to tests and screenings, which are judged based on sometimes arbitrarily-set numerical criteria, only to look for problems that do not yet exist or have not shown up yet as symptoms is a pseudo-scientific hoax that is promulgated by those who want to sell you tests and screenings and medications and “preventive” treatments, and is unfortunately left unopposed by doctors, many of whom are aware of the lack of any real scientific evidence to support the advantages of “early aggressive treatment,” but are too afraid of medical lawsuits to say no to their overzealous and paranoid patients who have become confused by the unrelenting demands of the healthcare industry for more tests and screenings. (Wow, that was a long sentence.)
This is a well-researched and well-presented book. It shows how the criteria for many diseases are arbitrarily set, and how the results of various studies are manipulated to mislead the general population to believe that it’s a good idea to get tested for all sorts of possible illnesses. Unfortunately many doctors have fallen for this myth too. (Not to offend any physicians out there, but most doctors are not scientists, and many of them have never designed or conducted a scientific experiment and don’t really know how to read the results of a large study and scrutinize its methods and check its claims and results. People need to keep this fact in mind before blindly following whatever their doctors tell them.) The reality is that even in the case of serious diseases like breast and prostate cancer, there’s really no evidence showing that it’s of any value for the younger and healthy people to undergo screening to look for these common cancer types early.
The moral of the book is: 1) If you feel fine, assume you’re fine. Don’t go looking for problems. 2) If you read an ad or see something on TV that tells you that early testing and screening “saves lives,” you can ignore it unless you’re good with statistics and are willing to pore over their study methodology and actual results and judge for yourself.
If you’ve been led to believe that it’s a good idea to get an annual physical checkup even though there’s nothing wrong with you, you need to read this book. The idea that it’s beneficial that we subject ourselves to tests and screenings, which are judged based on sometimes arbitrarily-set numerical criteria, only to look for problems that do not yet exist or have not shown up yet as symptoms is a pseudo-scientific hoax that is promulgated by those who want to sell you tests and screenings and medications and “preventive” treatments, and is unfortunately left unopposed by doctors, many of whom are aware of the lack of any real scientific evidence to support the advantages of “early aggressive treatment,” but are too afraid of medical lawsuits to say no to their overzealous and paranoid patients who have become confused by the unrelenting demands of the healthcare industry for more tests and screenings. (Wow, that was a long sentence.)
This is a well-researched and well-presented book. It shows how the criteria for many diseases are arbitrarily set, and how the results of various studies are manipulated to mislead the general population to believe that it’s a good idea to get tested for all sorts of possible illnesses. Unfortunately many doctors have fallen for this myth too. (Not to offend any physicians out there, but most doctors are not scientists, and many of them have never designed or conducted a scientific experiment and don’t really know how to read the results of a large study and scrutinize its methods and check its claims and results. People need to keep this fact in mind before blindly following whatever their doctors tell them.) The reality is that even in the case of serious diseases like breast and prostate cancer, there’s really no evidence showing that it’s of any value for the younger and healthy people to undergo screening to look for these common cancer types early.
The moral of the book is: 1) If you feel fine, assume you’re fine. Don’t go looking for problems. 2) If you read an ad or see something on TV that tells you that early testing and screening “saves lives,” you can ignore it unless you’re good with statistics and are willing to pore over their study methodology and actual results and judge for yourself.
April 14, 2018
Overdiagnosed: Making People Sick in the Pursuit of Health challenges the current mindset that it's always desirable and beneficial to obsessively screen healthy people for potential illnesses. Dr. Welch describes how actively pursuing illness in healthy people can actually be harmful to the patient.
Why is it bad to discover that people have diseases they don't know about and that have yet to create any symptoms? A few reasons are:
1) The medical-industrial complex continually lowers the numbers to give people more diseases.
2) Treating patients on the mild or borderline end of the disease spectrum often causes more harm than good.
3) The side effects of the treatments for patients with mild to moderate forms of a disease can be worse (and cause more discomfort and disruption) than the actual disease especially if they are asymptomatic.
4) Most people have "abnormalities" that would never cause them problems and are only diagnosed thanks to advanced medical imagining technologies.
5) There is the very real risk of false positives, causing patients to be treated for things such as prostate and thyroid cancer that they never actually had. This is not only expensive but can cause lasting harm in addition to the negative effects of the treatment.
6) Some abnormalities that are technically classified as cancers are genetically destined never to progress or cause a person symptoms.
7) Due a patient's age or other medical conditions, s/he will die of something else for the cancer progressed enough to cause symptoms or discomfort. So, diagnosing and treating them will not benefit the patient. In fact, it will only harm them emotionally, financially, and physically.
8) Rapid growing cancers that are also often resistant to treatment frequently are not caught by annual (or continual) preventive screenings because they develop so rapidly and can appear between screenings.
9) Actively searching for disease in asymptomatic patients further strains an already overburdened medical system.
10) The discovery of pre-existing conditions can result in the loss of medical insurance and the refusal for insurance companies to cover the costs of treatment.
11) The potential benefit of treatment commonly falls short of the actual benefit by a significant amount.
12) Many of the motives behind the push for preventative screens are not altruistic (i.e. motivating factors include profit and fear of lawsuits).
13) Patients are often encouraged to seek preventative screenings based on personal anecdotes rather than solid medical facts.
And the list goes on . . .
Chapter 1 discusses high blood pressure.
Chapter 2 discusses diabetes, high cholesterol, and osteoporosis.
Chapter 3 discusses medical imaging and the myriad of conditions such as bulging discs, blood clots, abdominal aortic aneurysms, damaged cartilage and gallstones that are often discovered when testing for other conditions.
Chapter 4 discusses prostate cancer, including the author's own reasons behind opting out of screening for it.
Chapter 5 discusses other cancers such as thyroid and colon cancer.
Chapter 6 discusses breast cancer.
Chapter 7 discusses "incidentalomas" that might or might not be cancerous.
Chapter 8 discusses other screenings such as cardiograms and ultrasounds.
Chapter 9 discusses genetic testing to determine if patients have elevated risks of developing certain diseases.
Chapter 10 is the author's conclusion.
The author's conclusion is not to avoid screening and medical treatments resulting from a positive test. Instead he councils patients to weigh the negative outcomes against any potential benefits before choosing to be screened. He also encourages patients to give careful consideration before consenting to treatment for any asymptomatic "abnormality" discovered when testing for other complaints.
The epidemic of overdiagnosis makes for an interesting albeit disturbing read. The statistics and charts occasionally make for dry reading, but overall the writing is accessible to all of us ordinary consumers of medical services.
Why is it bad to discover that people have diseases they don't know about and that have yet to create any symptoms? A few reasons are:
1) The medical-industrial complex continually lowers the numbers to give people more diseases.
2) Treating patients on the mild or borderline end of the disease spectrum often causes more harm than good.
3) The side effects of the treatments for patients with mild to moderate forms of a disease can be worse (and cause more discomfort and disruption) than the actual disease especially if they are asymptomatic.
4) Most people have "abnormalities" that would never cause them problems and are only diagnosed thanks to advanced medical imagining technologies.
5) There is the very real risk of false positives, causing patients to be treated for things such as prostate and thyroid cancer that they never actually had. This is not only expensive but can cause lasting harm in addition to the negative effects of the treatment.
6) Some abnormalities that are technically classified as cancers are genetically destined never to progress or cause a person symptoms.
7) Due a patient's age or other medical conditions, s/he will die of something else for the cancer progressed enough to cause symptoms or discomfort. So, diagnosing and treating them will not benefit the patient. In fact, it will only harm them emotionally, financially, and physically.
8) Rapid growing cancers that are also often resistant to treatment frequently are not caught by annual (or continual) preventive screenings because they develop so rapidly and can appear between screenings.
9) Actively searching for disease in asymptomatic patients further strains an already overburdened medical system.
10) The discovery of pre-existing conditions can result in the loss of medical insurance and the refusal for insurance companies to cover the costs of treatment.
11) The potential benefit of treatment commonly falls short of the actual benefit by a significant amount.
12) Many of the motives behind the push for preventative screens are not altruistic (i.e. motivating factors include profit and fear of lawsuits).
13) Patients are often encouraged to seek preventative screenings based on personal anecdotes rather than solid medical facts.
And the list goes on . . .
Chapter 1 discusses high blood pressure.
Chapter 2 discusses diabetes, high cholesterol, and osteoporosis.
Chapter 3 discusses medical imaging and the myriad of conditions such as bulging discs, blood clots, abdominal aortic aneurysms, damaged cartilage and gallstones that are often discovered when testing for other conditions.
Chapter 4 discusses prostate cancer, including the author's own reasons behind opting out of screening for it.
Chapter 5 discusses other cancers such as thyroid and colon cancer.
Chapter 6 discusses breast cancer.
Chapter 7 discusses "incidentalomas" that might or might not be cancerous.
Chapter 8 discusses other screenings such as cardiograms and ultrasounds.
Chapter 9 discusses genetic testing to determine if patients have elevated risks of developing certain diseases.
Chapter 10 is the author's conclusion.
The author's conclusion is not to avoid screening and medical treatments resulting from a positive test. Instead he councils patients to weigh the negative outcomes against any potential benefits before choosing to be screened. He also encourages patients to give careful consideration before consenting to treatment for any asymptomatic "abnormality" discovered when testing for other complaints.
The epidemic of overdiagnosis makes for an interesting albeit disturbing read. The statistics and charts occasionally make for dry reading, but overall the writing is accessible to all of us ordinary consumers of medical services.
April 24, 2011
This book is a lot better and more accurate than you would think. I happened upon it at the library. After looking at it for a week I was super bored and read it. Could not put it down! It explains how diagnostic tests have shifted (high cholesterol is now 200 and over where before it was 240 and over) after studies (paid for by drug companies-often) determined a lower threshold was needed. It also discusses how if you get enough tests you are bound to find something and that sometimes the treatment itself will cause more problems than if you left well enough alone. This is not a crazy book by some holistic weirdo. It is by a doctor whose wife actually had an aggressive form of breast cancer (not pertinant but puts it in perspective). Anyway, I was wary of reading it and it is a good and factual book. I highly recommend it to anyone who is old enough that doctors start recommending you get this test and that. Interestingly, it does tell you some tests (like colonoscopy) are very valid and important but others are bunk for 99% of the people who take them. I learned some useful stuff and no longer feel guilt over skipping the last 3 years of mammograms.
June 12, 2018
Tons of repetition for very good reasons. And some of them are excellently charted too.
This book gets specific. About certain human health conditions and the outcomes for "early find", "late find", no treatments etc.
It has specific issues to address re high blood pressure, cholesterol meds, yearly screenings for just about anything, check-ups etc. And how those patients react. Good, bad, or status quo.
And the relationship to longevity in this stats is truly amazing, IMHO.
The meds outcomes are especially informative. I myself knew one very similar to a man mentioned here whose meds one day just made his blood pressure too low. He fell down the stairs when he passed out and broke his neck. Which killed him instantly. Don't laugh. Side effects are very real. And concrete and stairs are everywhere.
This book gets specific. About certain human health conditions and the outcomes for "early find", "late find", no treatments etc.
It has specific issues to address re high blood pressure, cholesterol meds, yearly screenings for just about anything, check-ups etc. And how those patients react. Good, bad, or status quo.
And the relationship to longevity in this stats is truly amazing, IMHO.
The meds outcomes are especially informative. I myself knew one very similar to a man mentioned here whose meds one day just made his blood pressure too low. He fell down the stairs when he passed out and broke his neck. Which killed him instantly. Don't laugh. Side effects are very real. And concrete and stairs are everywhere.
May 2, 2020
Lest there be any doubt, it was doctors who created the opioid epidemic. Big Pharma was there, ready to pounce, but it was foolish, god-like thinking that set it up....
https://www.vox.com/2017/6/5/15111936...
==========
for those who don't have the time, or the inclination, to read the entire book, here's an excellent article by the author that captures his thesis. The metrics have just been arbitrarily lowered again on blood pressure (hypertension) to sell more pills.
http://dartmed.dartmouth.edu/winter10...
=====
The story of America's legal cartel that made a fortune off of oxycontin, including through "pill mills"...
https://www.newyorker.com/magazine/20...
https://www.vox.com/2017/6/5/15111936...
==========
for those who don't have the time, or the inclination, to read the entire book, here's an excellent article by the author that captures his thesis. The metrics have just been arbitrarily lowered again on blood pressure (hypertension) to sell more pills.
http://dartmed.dartmouth.edu/winter10...
=====
The story of America's legal cartel that made a fortune off of oxycontin, including through "pill mills"...
https://www.newyorker.com/magazine/20...
June 8, 2012
A very clear, well-reasoned, reader friendly, evidence-based argument for the view that preemptively hunting for health problems in asymptomatic people through routine screenings and tests, and lowering diagnostic thresholds (as has been done with high blood pressure, cholesterol, and diabetes), is not in the best interests of the vast majority of people. Many such early-intervention strategies do not lower the number of deaths from those diseases, result in false positives and overtreatment, and leave healthy people anxious, feeling that they are unwell, and sometimes financially burdened. They drive up the cost of medical care and insurance without giving bottom-line benefits, and may initiate unnecessary interventions, sometimes a whole cascade of potentially harmful treatments. The need is for authoritative medical trials to evaluate which screenings and treatments are effective, and which are ineffective or harmful. However, even when such trials show that a type of early detection is harmful, useless, or helps only a miniscule number of people, it is hard to change entrenched views of the medical industry or of the public.
July 31, 2016
More than 35 years ago my father died, too young, from pancreatic cancer. I learned at a young age that there were benign tumors and malignant tumors but I've always held the belief that if I have cancer in my body I want it removed. And sooner rather than later. And I would want to know as soon as possible.
Over the years I've heard that there were controversies about screening for and treating prostate and breast cancer. (These are discussed in the book and presented very well.) Who wouldn't want to know if they have these cancers and why wouldn't they opt for prostatectomies or mastectomies?
While I approached this book with a reservoir of skepticism I was also willing to keep an open mind. I have to say the author's use of plain language, patient stories and statistical data are extremely persuasive in arguing against routine screenings (PSA tests, mammograms and the like) and early surgical/medical interventions when symptoms are lacking. To be sure, the author (a physician) isn't saying you should stay away from doctors or ignore symptoms when the warning signs are visible.
Overall this is a very good book and one I would recommend to everyone.
Over the years I've heard that there were controversies about screening for and treating prostate and breast cancer. (These are discussed in the book and presented very well.) Who wouldn't want to know if they have these cancers and why wouldn't they opt for prostatectomies or mastectomies?
While I approached this book with a reservoir of skepticism I was also willing to keep an open mind. I have to say the author's use of plain language, patient stories and statistical data are extremely persuasive in arguing against routine screenings (PSA tests, mammograms and the like) and early surgical/medical interventions when symptoms are lacking. To be sure, the author (a physician) isn't saying you should stay away from doctors or ignore symptoms when the warning signs are visible.
Overall this is a very good book and one I would recommend to everyone.
March 29, 2021
Много хора живеят с идеята, че медицината е толкова напреднала, че едва ли не ще те излекува от смърт. Медицината е като всяко друго направление от нашия живот - гени, среда и чиста проба късмет. Нищо повече, нищо по-малко.
Книгата ми попадна съвсем случайно, но със сигурност ще прочета и останалите на автора, които са на същата тематика.
Трудно е да опиша книгата с едно изречение, тъй като всичко ми беше интересно, почти всеки абзац беше "Аха" момент, но простичко казано - книгата ти дава нова гледна точка към съвременната медицина и шанс да решиш за себе си дали профилактичните прегледи и изследвания са правилното нещо за теб и твоя живот. Честно казано, дава ти храна за размисъл, дали дори пред сериозна диагноза представена пред теб да направиш информирано решение в истинския смисъл на думата. :)
Разкошна книга, но ако сте от тези хора, които не биха се справили с мисълта, че докторите и медицината не са всесилни, може би не е добра идея да я четете.
Книгата ми попадна съвсем случайно, но със сигурност ще прочета и останалите на автора, които са на същата тематика.
Трудно е да опиша книгата с едно изречение, тъй като всичко ми беше интересно, почти всеки абзац беше "Аха" момент, но простичко казано - книгата ти дава нова гледна точка към съвременната медицина и шанс да решиш за себе си дали профилактичните прегледи и изследвания са правилното нещо за теб и твоя живот. Честно казано, дава ти храна за размисъл, дали дори пред сериозна диагноза представена пред теб да направиш информирано решение в истинския смисъл на думата. :)
Разкошна книга, но ако сте от тези хора, които не биха се справили с мисълта, че докторите и медицината не са всесилни, може би не е добра идея да я четете.
April 9, 2011
If you are interested in America's health care system, you should read this book. The authors are practicing physicians and bring both real world experience and an MD level understanding of clinical trials. We are moving from treating sick people that have definite symptoms to looking at healthy people with no symptoms in the hope that "early detection" will prevent sickness. With the advent of MRIs and CT scans, we are able to see much more than ever before. The cut offs for diagnosing high blood pressure and cholesterol keep getting lower.
The problem is, doctors are not good at determining what will result in actual disease progression. For example, finding very small cancer clusters via MRI/CT does not mean you will die from that disease. Often, the cancer either does not progress or goes away on its own. Prostate cancer is grossly over treated. There is no need to get fetal ultrasounds or have fetal heart monitors. Genetic testing alone is not a reliable indicator of getting the disease either.
The problem with all this testing is that people are over treated. They may get needless follow-up tests and interventions, which can often cause significant side effects, either short or long-term. People are more likely to suffer significant medication side effects when treating closer to normal values. And over treating makes no difference in life expectancy, but it will result in significant anxiety for the patient.
There is little chance that any of what this author is proposing will be adopted. The forces are too great for the desire to make profit, for MDs to avoid lawsuits, and for the well meaning advocacy groups to stay relevant. Our society has been inundated with messages scaring us into thinking that early detection is best, although any statistics that may be used in supporting their view is often misrepresented. The only hope is if individuals decide to limit interventions. I am one of them.
The problem is, doctors are not good at determining what will result in actual disease progression. For example, finding very small cancer clusters via MRI/CT does not mean you will die from that disease. Often, the cancer either does not progress or goes away on its own. Prostate cancer is grossly over treated. There is no need to get fetal ultrasounds or have fetal heart monitors. Genetic testing alone is not a reliable indicator of getting the disease either.
The problem with all this testing is that people are over treated. They may get needless follow-up tests and interventions, which can often cause significant side effects, either short or long-term. People are more likely to suffer significant medication side effects when treating closer to normal values. And over treating makes no difference in life expectancy, but it will result in significant anxiety for the patient.
There is little chance that any of what this author is proposing will be adopted. The forces are too great for the desire to make profit, for MDs to avoid lawsuits, and for the well meaning advocacy groups to stay relevant. Our society has been inundated with messages scaring us into thinking that early detection is best, although any statistics that may be used in supporting their view is often misrepresented. The only hope is if individuals decide to limit interventions. I am one of them.
August 25, 2017
I've always liked technical papers that have a graphic in them that summarizes the whole paper. Dr. Welch and his coauthors' sobering look at over-diagnosis can be summarized with one graph that they present in the opening chapters:
We've been screening for more and more in asymptomatic patients in the last 50 years, based on the premise that it would be better to catch things early and treat them. So, have patient outcomes improved? After several million people have been affected by this onslaught, the answer is no. Welch explains why and why it's often a bad idea to screen well people.
I spent 35 years working in a hospital laboratory. Our relationship with the clinicians was usually cordial and sometimes actually cooperative, but now and then it was adversarial. Problems included how to deal with the request for an inappropriate test (tests that didn't really exist; tests that couldn't be controlled; tests that were incredibly expensive - but the clinician's attitude was that neither they nor the patient was paying for it, so...; tests whose results could not be interpreted; tests whose results could not help the patient no matter what the result was), how to explain that if every test were done "stat", then none of them would be, and how to explain that if more and more biopsies were done for an "abnormal" test (e.g. a radiograph) with creeping criteria for positivity, then one might expect that most of those patients would not have abnormal pathologic findings. Many of these problems came down to a lack of knowledge of the statistical properties of reality. Dr. Welch covers several of these problems directly and some of them by implication. His book is a breath of fresh air.
We've been screening for more and more in asymptomatic patients in the last 50 years, based on the premise that it would be better to catch things early and treat them. So, have patient outcomes improved? After several million people have been affected by this onslaught, the answer is no. Welch explains why and why it's often a bad idea to screen well people.
I spent 35 years working in a hospital laboratory. Our relationship with the clinicians was usually cordial and sometimes actually cooperative, but now and then it was adversarial. Problems included how to deal with the request for an inappropriate test (tests that didn't really exist; tests that couldn't be controlled; tests that were incredibly expensive - but the clinician's attitude was that neither they nor the patient was paying for it, so...; tests whose results could not be interpreted; tests whose results could not help the patient no matter what the result was), how to explain that if every test were done "stat", then none of them would be, and how to explain that if more and more biopsies were done for an "abnormal" test (e.g. a radiograph) with creeping criteria for positivity, then one might expect that most of those patients would not have abnormal pathologic findings. Many of these problems came down to a lack of knowledge of the statistical properties of reality. Dr. Welch covers several of these problems directly and some of them by implication. His book is a breath of fresh air.
August 6, 2011
Dr. Welch was involved in an experiment in which a group of men who had had heart attacks were split into two groups, one of which was equipped with devices to measure irregularities & the other which was given the usual regular checkups. The experiment was discontinued when the researchers found that the device-equipped group received more treatment & died in greater numbers. This got the author looking for similar medical treatment phenomena.
If a form of cancer has become much more common over the years, the survival rate has improved, those receiving early detection live much longer than those who don't, & the over-all death rate from that form of cancer has stayed about the same over the years, there are two possible interpretations. One is that something is causing an increase in that form of cancer, while treatment of the cancer is improving. The other is that increased testing has led to treatment of people who would have never died from the form of cancer if it were left undiscovered & untreated. Dr. Welch argues that the latter is more likely.
Not a cheerful book, with a lot talk about disease & death, but thought-provoking & important.
If a form of cancer has become much more common over the years, the survival rate has improved, those receiving early detection live much longer than those who don't, & the over-all death rate from that form of cancer has stayed about the same over the years, there are two possible interpretations. One is that something is causing an increase in that form of cancer, while treatment of the cancer is improving. The other is that increased testing has led to treatment of people who would have never died from the form of cancer if it were left undiscovered & untreated. Dr. Welch argues that the latter is more likely.
Not a cheerful book, with a lot talk about disease & death, but thought-provoking & important.
July 4, 2020
Dr. Welch has written several books, most dealing with overuse of medical testing by doctors. I found this one, as well as a later book by him "Less Medicine, More Health" to be very eye-opening and informative. Dr. Welch urges patients as well as health care practitioners to rethink some procedures and tests which may do more harm than good by being too aggressive.
August 7, 2018
A book that all healthcare providers and consumers should read.
May 5, 2014
Everyone should read this book, but I fear that few will. Partly because it is perceived as a difficult topic. No worries there: Dr. Welch and his co-authors make this as easy and straightforward a read as possible. Even if you barely passed high school biology or math, you'll have no problems here: the science is simple, the statistics are very clearly explained.
Another reason folks might not read this is that they are comfortable delegating their personal health decisions to physicians. The facts indicate that this is not a good plan. The whole point of Dr. Welch's research is that physicians often do things that provide no statistically significant improvement to lifespan but do have a statistically significant likelihood of negative side effects.
If your auto mechanic suggests an expensive diagnostic for your engine when you bring your well-running car in for a routine oil change, and then suggests a follow on test because the first was inconclusive, and these are expensive tests, and there's a chance that your engine will be ruined by the testing, you might want to have a better sense of what's going on. If all this happens while your car is running perfectly well, with no symptoms of trouble, then you're in a situation quite analogous to the superfluous diagnostic medical scanning that Dr. Welch writes about.
Dr. Welch is careful to not pick on his colleagues. Although he does note that a physician's primary sources of information tend to be funded by drug companies or medical equipment manufactures. In addition, there are many economic reasons to ignore science and statistics, sub-conscious or not. A big factor is that a doctor, like anyone else, is often most comfortable with the "old wives tales" that they know. This sort of thing has gone on for centuries. One example, not from the book, is that of Dr. Ignaz Semmelweis.
Semmelweis noticed that mothers would give birth in a hospital's obstetrical clinic only to die of puerperal fever soon after -- with a mortality rate of 10% to 35%. That's a scary amount of preventable death for a hospital. He determined that if doctors would wash their hands with a chlorinated lime solution (similar to today's anti-bacterial soaps), they could take the mortality rate down to below 1%. You don't need to be a doctor nor a statistician to see that this is a good deal. So what happened?
In spite of published facts, Semmelweis' observations conflicted with the established, normative medical practice of the time. So his ideas were soundly rejected. It took about 20 years before Dr. Joseph Lister succeeded in getting doctors to accept the science, and only then because he built on the concepts that Louis Pasteur introduced. Most folks have heard of Listerine mouthwash, named after Lister. Nothing is named after Semmelweiss. But lots of women died in those intervening years.
I use this example because it is so very obvious to us today that one should wash one's hands -- and yet, it took decades to get doctors to do it. It is difficult to realize sometimes that throughout history scientists have been labeled heretics because their data did not conform to then-current practice. In the 21st century we tend to feel as though every problem has been solved, and that we've got it all right. But maybe not so much, and Dr. Welch's book points out clear examples of facts not convincing physicians. This problem of normal practice not aligning with the facts, but going on anyways, is old news. It happened to Galileo, who had the audacity to propose that the earth rotates around the sun. It happened to Semmelweiss, and many others. And as Dr. Welch's book makes quite clear, it happens yet today.
Okay, so back to the book for some modern day examples. Back in 1996, the US Preventative Services Task Force (USPSTF) recommended against routine obstetrical ultrasound. Why? Because they found that there is just no substantive benefit. The highly respected Cochrane Collaboration (which eschews any financial support from drug firms or equipment companies) agrees. But every single expectant mother that I have met since 1996 gets an ultrasound; I bet that's true for you too. The USPSTF has given up on the topic, because they recognize that this unhelpful and potentially negative scanning procedure is such a common practice that no one would listen to them anyway. [pp112-113] Yikes.
But there's more. Also in 1996, the USPSTF recommended against routine fetal monitoring (the belt put around an expectant mother to monitor the about-to-be-born baby's heart beat). Once again, the Cochrane Collaboration agreed, noting that monitoring increased C-section rates by 66%, and that the risk of that to baby and mother is enormously worse than the potential benefit. What is that benefit?
About one in a thousand babies would avoid a (non-fatal) seizure compared to two in a thousand without the monitoring. A one in a thousand change. But even then, no improvement in baby's health as measured by Apgar score, respiration, pulse, conditions like cerebral palsy, need for ICU - nothing. Yet, again, it is such a common practice that the agency feels it would be tilting at windmills to try to change it (even though doing so would clearly, from the numbers, save lives and reduce negative side effects). [pp105-106] Did I say, Yikes?
There's lots more in the book, from mammograms to PSA tests to blood pressure and diabetes.
By now you should be considering that there is real value in reading this book, if only to make us better informed consumers of the medical industry.
Dr. Welch has done an extraordinary job of stating the facts, acknowledging the ambiguities, and making it clearer for individuals to understand the tradeoffs of their diagnostic scanning choices. Even if you continue to use screening that the facts might indicate you oughtn't, you'll have a better understanding of what the issues are.
Another reason folks might not read this is that they are comfortable delegating their personal health decisions to physicians. The facts indicate that this is not a good plan. The whole point of Dr. Welch's research is that physicians often do things that provide no statistically significant improvement to lifespan but do have a statistically significant likelihood of negative side effects.
If your auto mechanic suggests an expensive diagnostic for your engine when you bring your well-running car in for a routine oil change, and then suggests a follow on test because the first was inconclusive, and these are expensive tests, and there's a chance that your engine will be ruined by the testing, you might want to have a better sense of what's going on. If all this happens while your car is running perfectly well, with no symptoms of trouble, then you're in a situation quite analogous to the superfluous diagnostic medical scanning that Dr. Welch writes about.
Dr. Welch is careful to not pick on his colleagues. Although he does note that a physician's primary sources of information tend to be funded by drug companies or medical equipment manufactures. In addition, there are many economic reasons to ignore science and statistics, sub-conscious or not. A big factor is that a doctor, like anyone else, is often most comfortable with the "old wives tales" that they know. This sort of thing has gone on for centuries. One example, not from the book, is that of Dr. Ignaz Semmelweis.
Semmelweis noticed that mothers would give birth in a hospital's obstetrical clinic only to die of puerperal fever soon after -- with a mortality rate of 10% to 35%. That's a scary amount of preventable death for a hospital. He determined that if doctors would wash their hands with a chlorinated lime solution (similar to today's anti-bacterial soaps), they could take the mortality rate down to below 1%. You don't need to be a doctor nor a statistician to see that this is a good deal. So what happened?
In spite of published facts, Semmelweis' observations conflicted with the established, normative medical practice of the time. So his ideas were soundly rejected. It took about 20 years before Dr. Joseph Lister succeeded in getting doctors to accept the science, and only then because he built on the concepts that Louis Pasteur introduced. Most folks have heard of Listerine mouthwash, named after Lister. Nothing is named after Semmelweiss. But lots of women died in those intervening years.
I use this example because it is so very obvious to us today that one should wash one's hands -- and yet, it took decades to get doctors to do it. It is difficult to realize sometimes that throughout history scientists have been labeled heretics because their data did not conform to then-current practice. In the 21st century we tend to feel as though every problem has been solved, and that we've got it all right. But maybe not so much, and Dr. Welch's book points out clear examples of facts not convincing physicians. This problem of normal practice not aligning with the facts, but going on anyways, is old news. It happened to Galileo, who had the audacity to propose that the earth rotates around the sun. It happened to Semmelweiss, and many others. And as Dr. Welch's book makes quite clear, it happens yet today.
Okay, so back to the book for some modern day examples. Back in 1996, the US Preventative Services Task Force (USPSTF) recommended against routine obstetrical ultrasound. Why? Because they found that there is just no substantive benefit. The highly respected Cochrane Collaboration (which eschews any financial support from drug firms or equipment companies) agrees. But every single expectant mother that I have met since 1996 gets an ultrasound; I bet that's true for you too. The USPSTF has given up on the topic, because they recognize that this unhelpful and potentially negative scanning procedure is such a common practice that no one would listen to them anyway. [pp112-113] Yikes.
But there's more. Also in 1996, the USPSTF recommended against routine fetal monitoring (the belt put around an expectant mother to monitor the about-to-be-born baby's heart beat). Once again, the Cochrane Collaboration agreed, noting that monitoring increased C-section rates by 66%, and that the risk of that to baby and mother is enormously worse than the potential benefit. What is that benefit?
About one in a thousand babies would avoid a (non-fatal) seizure compared to two in a thousand without the monitoring. A one in a thousand change. But even then, no improvement in baby's health as measured by Apgar score, respiration, pulse, conditions like cerebral palsy, need for ICU - nothing. Yet, again, it is such a common practice that the agency feels it would be tilting at windmills to try to change it (even though doing so would clearly, from the numbers, save lives and reduce negative side effects). [pp105-106] Did I say, Yikes?
There's lots more in the book, from mammograms to PSA tests to blood pressure and diabetes.
By now you should be considering that there is real value in reading this book, if only to make us better informed consumers of the medical industry.
Dr. Welch has done an extraordinary job of stating the facts, acknowledging the ambiguities, and making it clearer for individuals to understand the tradeoffs of their diagnostic scanning choices. Even if you continue to use screening that the facts might indicate you oughtn't, you'll have a better understanding of what the issues are.
March 31, 2022
This book completely changed the way I think about healthcare and I wholeheartedly agree with the author describing over-diagnosis as “the biggest problem posed by modern medicine.”
May 31, 2022
كتاب مهم جداً للعاملين في الحقل الطبي، يُقرأ بحرص وتأني كبيرين، وذلك لمعارضته لكثير مما هو متفق عليه في العرف الطبي.
يتمحور الكتاب حول فكرة أساسية وهي: الافراط في التشخيص -بترجمتي- وهي من بين ما تعني: البحث الاستقصائي في جسم الانسان بإجراء فحوصات معينة، وذلك لغرض إيجاد مرض/مشكلة، لم تسبب للشخص أي أعراض بعد. وحين اكتشاف المشكلة التعامل معها بتدخل طبي محدد.
يناقش الكاتب، وهو طبيب وباحث، هذه الفكرة من خلال عرض طويل وتفصيلي لعدة آليات منها الفحص المبكر لأمراض مثل ارتفاع ضغط الدم، السكري من النوع الثاني، وعدد من أنواع السرطان كسرطان البروستات والثدي والغدة الدرقية. ويصل إلى نتيجة مفادها أن هذا النوع من البحث الاستقصائي عن المشاكل ،في غالبه، يضر أكثر مما ينفع. وأن البيانات المتوفرة حالياً لأكثر الفحوصات شيوعاً، غير دقيقة ومبنية على دراسات غير مُحكمة. وأن ما يترتب عليها من تدخلات طبية مثل فحوصات أكثر، تلقي أدوية غير ضرورية، اجراء جراحات ذات مخاطر عالية، في عدد كبير منها غير ضروري وله آثار سلبية كثيرة.
يرى دكتور ويلش أن لذلك أسباب منها: جهل المرضى وكثير من الأطراف بكل البيانات العلمية المتوفرة، تداخل المصالح بين شركات الأدوية/شركات المعدات الطبية/المستشفيات والمعامل الخاصة/الخوف من الملاحقة القانونية الطبية/عدم تحمل انعدام الاجابات لكثير من الأعراض، وغيرها من الأسباب.
وينتهي دكتور ويلش إلى القول بضرورة تمكين المرضى، بتنويرهم بالصورة الكاملة لمثل تلك المقاربات. وباجراء المزيد من الدراسات المحكمة للتحقق من قوة هذه الفحوصات، وأخيراً التركيز على تعزيز الصحة أكثر من البحث عن الأمراض.
أتمنى أن تصدر نسخة محدثة من الكتاب، لنرى إلى أي وصل عالم الافراط في التشخيص. خصوصاً بعد مرور قرابة العقد على صدوره.
يتمحور الكتاب حول فكرة أساسية وهي: الافراط في التشخيص -بترجمتي- وهي من بين ما تعني: البحث الاستقصائي في جسم الانسان بإجراء فحوصات معينة، وذلك لغرض إيجاد مرض/مشكلة، لم تسبب للشخص أي أعراض بعد. وحين اكتشاف المشكلة التعامل معها بتدخل طبي محدد.
يناقش الكاتب، وهو طبيب وباحث، هذه الفكرة من خلال عرض طويل وتفصيلي لعدة آليات منها الفحص المبكر لأمراض مثل ارتفاع ضغط الدم، السكري من النوع الثاني، وعدد من أنواع السرطان كسرطان البروستات والثدي والغدة الدرقية. ويصل إلى نتيجة مفادها أن هذا النوع من البحث الاستقصائي عن المشاكل ،في غالبه، يضر أكثر مما ينفع. وأن البيانات المتوفرة حالياً لأكثر الفحوصات شيوعاً، غير دقيقة ومبنية على دراسات غير مُحكمة. وأن ما يترتب عليها من تدخلات طبية مثل فحوصات أكثر، تلقي أدوية غير ضرورية، اجراء جراحات ذات مخاطر عالية، في عدد كبير منها غير ضروري وله آثار سلبية كثيرة.
يرى دكتور ويلش أن لذلك أسباب منها: جهل المرضى وكثير من الأطراف بكل البيانات العلمية المتوفرة، تداخل المصالح بين شركات الأدوية/شركات المعدات الطبية/المستشفيات والمعامل الخاصة/الخوف من الملاحقة القانونية الطبية/عدم تحمل انعدام الاجابات لكثير من الأعراض، وغيرها من الأسباب.
وينتهي دكتور ويلش إلى القول بضرورة تمكين المرضى، بتنويرهم بالصورة الكاملة لمثل تلك المقاربات. وباجراء المزيد من الدراسات المحكمة للتحقق من قوة هذه الفحوصات، وأخيراً التركيز على تعزيز الصحة أكثر من البحث عن الأمراض.
أتمنى أن تصدر نسخة محدثة من الكتاب، لنرى إلى أي وصل عالم الافراط في التشخيص. خصوصاً بعد مرور قرابة العقد على صدوره.
March 3, 2011
'Overdiagnosed' is, without a doubt, an important book. It convincingly shows that if we look harder for a disease, we find more "abnormalities" but we're not preventing any deaths. Instead, the more people are subjected to unneccesary medical procedures, which can be just scary, expersive and annoying but also debilitating or even lethal.
The authors explains how this happens with great clarity. Let's say, as an example, that each year a hundred women find a lump in their breast. They go and see a doctor, who does an autopsy and confirmes it's breastcancer. All these women are treated. 90 get better, 10 die. Now, let's travel one year back in time. All 100.000 women in a town our having mammography to screen for early signs of breastcancer. Even though our hundred women wouldn't have lumps in their breasts yet, the mammography will show an abnormality. But they will not be the only ones with an abnormality. Research shows that up to 40 percent of all women have some sort of 'could be cancer could be nothing' in their breasts. This means that screening will not only raise a red flag for our 100 women who would have developed clinical symptoms of breastcancer (eg a lump) but also for up to 39.900 other women in their town. They will be scared, have biopsies, maybe have their breasts removed, just like our 100, but they were never destined to develop clinical symptoms. That would all be fine, if early detection of asymptomatic breastcancer would save a lot of lives. But as Gilbert Welch shows, it doesn't. Mortality rates have not gone down since wide spread breastcancer screening was introduced. So those 39.900 women were not lucky, they were overdiagnosed, because their abnormality would never have progressed into lethal cancer.
Breastcancer, ofcourse, is just an example. Almost every disease or condition (high blood pressure, diabetes, high cholesterol, prostate cancer as notable examples) that we screen for in a large group of healthy individuals is prone to overdiagnosis. This is because, as Welch argues, the most serieus cases - which are also the ones to benefit most from treatment, because they are sicker and thus have more to loose and more to gain - don't need the screening: they will present with symptoms and see their doctor anyway. So screening mostly diagnoses relatively mild cases, people who otherwise feel ok. This 'mildly abnormal' group is, as in the breastcancer example above, much much larger than the 'dangerously ill' group. So what screening does is tranforming a large group of otherwise healthy people into patients by giving them an early diagnosis of a disease that may never progress to giving clinical symptoms. In other words: it makes patients out of healthy people who, even in the future, may have never gotten ill. And, to add insult to (nonexistent) injury, these now 'not symptomatic but worried' patients only really benefit from medical treatment until they do become symptomatic. But since they are also worried, and doctors are uncomfortabke doing nothing, they probably will get treatment, and suffer all the risks and side effects from it.
Welch's remedy is simple: if research shows early detection has no benefits because it does not prevent suffering or death (as is the case for all examples I mentioned) don't go out and screen lots and lots of healthy people. Instead tell patients to visit their doctors as soon as a symptom occurs, find out what's wrong and treat accordingly. It will save just as many lives, but it will spare healthy but slightly 'abnormal' people ghe expense, anxiety and pain of being overdiagnosed.
The authors explains how this happens with great clarity. Let's say, as an example, that each year a hundred women find a lump in their breast. They go and see a doctor, who does an autopsy and confirmes it's breastcancer. All these women are treated. 90 get better, 10 die. Now, let's travel one year back in time. All 100.000 women in a town our having mammography to screen for early signs of breastcancer. Even though our hundred women wouldn't have lumps in their breasts yet, the mammography will show an abnormality. But they will not be the only ones with an abnormality. Research shows that up to 40 percent of all women have some sort of 'could be cancer could be nothing' in their breasts. This means that screening will not only raise a red flag for our 100 women who would have developed clinical symptoms of breastcancer (eg a lump) but also for up to 39.900 other women in their town. They will be scared, have biopsies, maybe have their breasts removed, just like our 100, but they were never destined to develop clinical symptoms. That would all be fine, if early detection of asymptomatic breastcancer would save a lot of lives. But as Gilbert Welch shows, it doesn't. Mortality rates have not gone down since wide spread breastcancer screening was introduced. So those 39.900 women were not lucky, they were overdiagnosed, because their abnormality would never have progressed into lethal cancer.
Breastcancer, ofcourse, is just an example. Almost every disease or condition (high blood pressure, diabetes, high cholesterol, prostate cancer as notable examples) that we screen for in a large group of healthy individuals is prone to overdiagnosis. This is because, as Welch argues, the most serieus cases - which are also the ones to benefit most from treatment, because they are sicker and thus have more to loose and more to gain - don't need the screening: they will present with symptoms and see their doctor anyway. So screening mostly diagnoses relatively mild cases, people who otherwise feel ok. This 'mildly abnormal' group is, as in the breastcancer example above, much much larger than the 'dangerously ill' group. So what screening does is tranforming a large group of otherwise healthy people into patients by giving them an early diagnosis of a disease that may never progress to giving clinical symptoms. In other words: it makes patients out of healthy people who, even in the future, may have never gotten ill. And, to add insult to (nonexistent) injury, these now 'not symptomatic but worried' patients only really benefit from medical treatment until they do become symptomatic. But since they are also worried, and doctors are uncomfortabke doing nothing, they probably will get treatment, and suffer all the risks and side effects from it.
Welch's remedy is simple: if research shows early detection has no benefits because it does not prevent suffering or death (as is the case for all examples I mentioned) don't go out and screen lots and lots of healthy people. Instead tell patients to visit their doctors as soon as a symptom occurs, find out what's wrong and treat accordingly. It will save just as many lives, but it will spare healthy but slightly 'abnormal' people ghe expense, anxiety and pain of being overdiagnosed.
February 25, 2022
Outstanding. Anyone who is likely to directly or indirectly encounter the US healthcare system (so everyone?) should read this. It is so packed with great information, I can't hope to summarize it in one short review, but suffice it to say, it provides desperately needed context and background for early diagnosis/early detection. Most public health messaging/media portrayal of early diagnosis/screening/testing, etc. presents these tools as - to use the authors' language - "unambiguously good." However, I think most of us, if we really stop to think about it, would realize there are very few things in life that are truly unambiguously good. Most things have pros and cons, upsides and downsides, advantages and disadvantages. The same is true of early diagnosis/screening, and the authors strive to bring that balanced approach to the masses by presenting the data in a measured, plain-language manner.
To put it in Bayesian terms, this book caused me to update my priors on a whole bunch of topics. The early cancer screening and genetic testing sections were particularly eye-opening and illuminating for me personally (perhaps because I am already fairly up to speed on the real harms arising out of excessive or unnecessary imaging for musculoskeletal concerns). The discussion of how nuanced and complex the medical regulatory landscape is, especially as it relates to drivers of public health messaging and recommendations, was excellent.
A couple of the key takeaways for me were to learn to ask not only is a diagnostic test/screening beneficial, but HOW beneficial is it? Does the benefit wane in the case of a minor abnormality or minimally advanced disease state? How much cost (not necessarily monetary, but in terms of time, hassle, pain, etc.) is involved in obtaining the potential benefit? Because in many cases presented in the book, it's pretty clear that particularly with asymptomatic individuals or those with mild abnormalities, the potential costs may outweigh (sometimes very significantly) the likely benefits. The book also crystallized for me that all abnormalities and/or disease states are on a spectrum, and those who are at the far end (in terms of severity) are those who are most likely to receive large benefits from early detection and treatment. The further down the spectrum you go (in general), the more nebulous those benefits become - and potential downsides (in some cases) increase dramatically.
Finally, I loved the authors' conclusion that "health is not just the absence of disease" - it's much more than that. This view is in contrast to the fear-centered narrative that is often (but not always) used to promote early screening and diagnosis. I especially appreciated their conclusion that perhaps we should spend more time encouraging people to view themselves as robust, resilient, and adaptable creatures and equipping them to self-manage when faced with adversity (inevitable for most humans) so we work to improve not only longevity but also quality of that longer life.
Lastly, this is not an indictment of medical professionals or the broader healthcare community. I would have found such a tone off-putting given that I have dear family and friends who are members of this community and I generally have nothing but respect for those involved in our healthcare system. If anything, the book attempts to help healthcare consumers understand the complicated web of concerns their providers must navigate on a daily basis, so that patients can ask better questions and make better use of the time they have with a provider.
To put it in Bayesian terms, this book caused me to update my priors on a whole bunch of topics. The early cancer screening and genetic testing sections were particularly eye-opening and illuminating for me personally (perhaps because I am already fairly up to speed on the real harms arising out of excessive or unnecessary imaging for musculoskeletal concerns). The discussion of how nuanced and complex the medical regulatory landscape is, especially as it relates to drivers of public health messaging and recommendations, was excellent.
A couple of the key takeaways for me were to learn to ask not only is a diagnostic test/screening beneficial, but HOW beneficial is it? Does the benefit wane in the case of a minor abnormality or minimally advanced disease state? How much cost (not necessarily monetary, but in terms of time, hassle, pain, etc.) is involved in obtaining the potential benefit? Because in many cases presented in the book, it's pretty clear that particularly with asymptomatic individuals or those with mild abnormalities, the potential costs may outweigh (sometimes very significantly) the likely benefits. The book also crystallized for me that all abnormalities and/or disease states are on a spectrum, and those who are at the far end (in terms of severity) are those who are most likely to receive large benefits from early detection and treatment. The further down the spectrum you go (in general), the more nebulous those benefits become - and potential downsides (in some cases) increase dramatically.
Finally, I loved the authors' conclusion that "health is not just the absence of disease" - it's much more than that. This view is in contrast to the fear-centered narrative that is often (but not always) used to promote early screening and diagnosis. I especially appreciated their conclusion that perhaps we should spend more time encouraging people to view themselves as robust, resilient, and adaptable creatures and equipping them to self-manage when faced with adversity (inevitable for most humans) so we work to improve not only longevity but also quality of that longer life.
Lastly, this is not an indictment of medical professionals or the broader healthcare community. I would have found such a tone off-putting given that I have dear family and friends who are members of this community and I generally have nothing but respect for those involved in our healthcare system. If anything, the book attempts to help healthcare consumers understand the complicated web of concerns their providers must navigate on a daily basis, so that patients can ask better questions and make better use of the time they have with a provider.
January 1, 2014
I found myself feeling dubious about some of the claims. I also found myself wishing for more detail. Basically, the concept is that doing hunting expeditions for diseases isn't a good idea. He is all for what he calls diagnostic screening: if the patient goes to the doctor with a lump or something. He is very opposed to screening being done routinely and explains why in convincing detail. I'm just not completely convinced. My father in law was diagnosed with colon cancer after getting a toilet bowl of blood. Colon cancer is 95% fatal in 4th stage. In 1st stage it is 95% curable. I think it quite likely my father in law might be alive today if he had ever had routine screening for this. Dr. Welch's point would be that a lot of unnecessary polyps might be removed from the screening. The main argument Dr. Welch has against regular screening is that so often it is a case of over diagnosis and the consequences are frequently worse than just doing nothing would have been. In other words, ignorance can be bliss. I can't disagree with him completely by any means. I found myself running to check my numbers for cholesterol and blood pressure on the health company website. I've been getting some pressure to both go on high blood pressure meds and cholesterol meds. According to Dr. Welch, my numbers are actually fairly low which isn't the impression I've gotten from the organization. My feeling had been all along that I wasn't so sure I wanted to do this and now I am sure I do not want to start meds until and if my numbers are considerably higher. Basically, the concept is that the cure can be worse than the disease. A lot of this of course is fear of lawsuits. As the Dr. pointed out, Drs never get sued for suggesting tests. They get sued for not suggesting tests. I would say that the answer as always is more education. The patient needs to decide if the possible result of screening is something they wish to do or not, and why. The Dr was after my Dad for years to get his cholesterol tested and my Dad always refused to her great frustration. He died from liver problems that had nothing to do with cholesterol issues. So ultimately my Dad was right for him. Did I mention he was 89 at death? Even if it had been cholesterol that killed him, would it have been such a tragedy at his age as opposed to suffering the side effects of statins for decades? I just don't know. I plan on seeing if the doctor has a website with more detail. I also think that my ordinary skepticism in dealing with doctors is justified by this book. I want reasons for why I should do something. Don't just tell me to take a test without explaining all about the possible consequences.
June 12, 2020
A fantastic take on a wave, although done with the best of intentions most of the time, tends to do more harm than good for patients. Its harmful effects extend to healthcare systems as a whole too. His book, as well as his research, are definitely worth the time!
December 15, 2022
A real eye opener!
September 30, 2024
books like this make me realize that I learn a lot more in school than I think I do
I didn’t really learn anything new, but this is a good summary about issues with screening and overdiagnosing for people that want to read about it. Sadly all of the chapters on different types of cancer and their screenings got too repetitive and I got kinda bored
3.5
I didn’t really learn anything new, but this is a good summary about issues with screening and overdiagnosing for people that want to read about it. Sadly all of the chapters on different types of cancer and their screenings got too repetitive and I got kinda bored
3.5
December 27, 2023
Screening tests for diseases including prostate cancer, breast cancer, colon cancer, osteoporosis, high cholesterol, and others are not as effective or necessary as we've been led to believe. The author posits that (not without exceptions) if we don't have symptoms, it's most likely that we don't need treatments. Unnecessary screening tests uncover possibly early cases of diseases, but the question is, how many people do they save from early death (undoubtedly some) and how many people are damaged by unnecessary additional testing, diagnoses, and treatments (undoubtedly many more).
He analyzes statistics from available studies on a number of illnesses to demonstrate the fact that screening in asymptomatic people probably harms more people than it helps. Screening and treatment also inflate the number of cases and the cure rate. If the screening uncovers mild cases that would never progress into a damaging disease, or that would be no harder to treat if they were discovered later, it skews that data to make it look like there are more cases and higher cure rates than before screening.
Positive screening results fall into three categories. For cancers, screening may find an aggressive cancer that is going to kill someone anyway (in this case early discovery may or may not prolong life, but not for all that long). It may uncover something that was never going to progress into a life-threatening cancer, and that could have been diagnosed and cured later if it did progress. The third category, where early discovery leads to a cure, is far less common than the other two.
So why do we do all this screening? Why do we ignore studies that say mammography should start at a later age and be less frequent? Why do we still do routine PSAs for prostate cancer when they've been found to not affect the death rate? Why do we load people up with drugs for levels of hypertension or cholesterol or blood sugar that are not causing symptoms and that would not have been considered a problem before we changed guidelines?
There are several reasons. Big pharma and the medical device industries push tests and treatments for profit, of course, as do a (relatively) small number of doctors/hospitals/screening centers. Fear of malpractice lawsuits certainly motivates doctors to do tests that they know are unnecessary. And then there's fear of disease. Every doctor has seen a death that probably could have been prevented with earlier care, and every person knows someone who probably-unnecessarily died. They are true believers. Organizations dedicated to helping with specific diseases also have an element of true belief, but they are most often sponsored by for-profit corporations.
One thing the author doesn't do is to try to quantify the number of cancers actually caused by the radiation from screening like mammograms and especially CAT scans. He mentions in passing that radiation causes cancer, but doesn't go farther than that.
The author tells where his data comes from, and explains every step of analyzing the data and coming to his conclusions. It's not the easiest read - it's dense, and I didn't manage to read more than a few chapters a day. But it's excellent. It all makes perfect sense to me, and validates my long-time decision to not have most recommended screenings.
This book is nine years old now. I don't know how much has changed in that time, but I suspect not much. I think the book is extremely important and recommend it to everyone.
He analyzes statistics from available studies on a number of illnesses to demonstrate the fact that screening in asymptomatic people probably harms more people than it helps. Screening and treatment also inflate the number of cases and the cure rate. If the screening uncovers mild cases that would never progress into a damaging disease, or that would be no harder to treat if they were discovered later, it skews that data to make it look like there are more cases and higher cure rates than before screening.
Positive screening results fall into three categories. For cancers, screening may find an aggressive cancer that is going to kill someone anyway (in this case early discovery may or may not prolong life, but not for all that long). It may uncover something that was never going to progress into a life-threatening cancer, and that could have been diagnosed and cured later if it did progress. The third category, where early discovery leads to a cure, is far less common than the other two.
So why do we do all this screening? Why do we ignore studies that say mammography should start at a later age and be less frequent? Why do we still do routine PSAs for prostate cancer when they've been found to not affect the death rate? Why do we load people up with drugs for levels of hypertension or cholesterol or blood sugar that are not causing symptoms and that would not have been considered a problem before we changed guidelines?
There are several reasons. Big pharma and the medical device industries push tests and treatments for profit, of course, as do a (relatively) small number of doctors/hospitals/screening centers. Fear of malpractice lawsuits certainly motivates doctors to do tests that they know are unnecessary. And then there's fear of disease. Every doctor has seen a death that probably could have been prevented with earlier care, and every person knows someone who probably-unnecessarily died. They are true believers. Organizations dedicated to helping with specific diseases also have an element of true belief, but they are most often sponsored by for-profit corporations.
One thing the author doesn't do is to try to quantify the number of cancers actually caused by the radiation from screening like mammograms and especially CAT scans. He mentions in passing that radiation causes cancer, but doesn't go farther than that.
The author tells where his data comes from, and explains every step of analyzing the data and coming to his conclusions. It's not the easiest read - it's dense, and I didn't manage to read more than a few chapters a day. But it's excellent. It all makes perfect sense to me, and validates my long-time decision to not have most recommended screenings.
This book is nine years old now. I don't know how much has changed in that time, but I suspect not much. I think the book is extremely important and recommend it to everyone.
August 20, 2018
The author's position is that the medical community is over-diagnosing ailments through the process of screening. This trend is exacerbated by decreasing the limits at which a condition is considered a concern requiring further testing or intervention.
Meanwhile the indicators of abnormal conditions have been changed to become more stringent. The cut-off for diabetes has been changed from a fasting sugar level of 140 to 126, meaning an extra 1.6 million Americans (14 percent increase) have diabetes. The measure of hypertension has changed from 100 to 90 diastolic and 160 to 140 systolic, producing an extra 13 million Americans (35 percent increase) with hypertension. The adjustment of the limit for hyperlipidemia (total cholesterol from 240 to 200) increased the number of people with the condition by over 42 million (86 percent increase).
The adjustment of these indicators is a particular concern as treatment at the lower end of concern often produces marginal results. For example, treatment of very mild hypertension (diastolic blood pressure 90-100) provides only a 6 percent chance of benefit - 18 people must be treated for one to benefit. Of 100 patients with treated for mildly high cholesterol, 8 would be saved from a heart attack but 78 would be needlessly treated.
The problem with unneeded treatment is that it often has negative impacts including increased anxiety, adverse reactions to the treatments and an ongoing stream of testing.
The improving imaging technologies are showing that people have many abnormalities that never result in medical problems. These include gallstones, meniscal tears in the knee, bulging lumbar discs, smaller aortic aneurysms, blood clots, incidental tumors (incidentalomas) and thyroid nodules.
DNA testing can lead to over-diagnosis. While certain genes have been found to be associated with specific diseases, the correlation is often low. The effect of a given gene on one's phenotype - physical, biochemical and behavioral characteristics - varies over a large range. This factor is known as penetrance, and is only large for a few genes such as those for cystic fibrosis.
While over-diagnosis can provide an easy revenue stream for certain doctors, laboratories and pharmeceutical companies, the greater push seems to be from a desire to whatever possible to find disease. Potential liability is also an issue.
A well written book from a doctor who understands statistics.
Meanwhile the indicators of abnormal conditions have been changed to become more stringent. The cut-off for diabetes has been changed from a fasting sugar level of 140 to 126, meaning an extra 1.6 million Americans (14 percent increase) have diabetes. The measure of hypertension has changed from 100 to 90 diastolic and 160 to 140 systolic, producing an extra 13 million Americans (35 percent increase) with hypertension. The adjustment of the limit for hyperlipidemia (total cholesterol from 240 to 200) increased the number of people with the condition by over 42 million (86 percent increase).
The adjustment of these indicators is a particular concern as treatment at the lower end of concern often produces marginal results. For example, treatment of very mild hypertension (diastolic blood pressure 90-100) provides only a 6 percent chance of benefit - 18 people must be treated for one to benefit. Of 100 patients with treated for mildly high cholesterol, 8 would be saved from a heart attack but 78 would be needlessly treated.
The problem with unneeded treatment is that it often has negative impacts including increased anxiety, adverse reactions to the treatments and an ongoing stream of testing.
The improving imaging technologies are showing that people have many abnormalities that never result in medical problems. These include gallstones, meniscal tears in the knee, bulging lumbar discs, smaller aortic aneurysms, blood clots, incidental tumors (incidentalomas) and thyroid nodules.
DNA testing can lead to over-diagnosis. While certain genes have been found to be associated with specific diseases, the correlation is often low. The effect of a given gene on one's phenotype - physical, biochemical and behavioral characteristics - varies over a large range. This factor is known as penetrance, and is only large for a few genes such as those for cystic fibrosis.
While over-diagnosis can provide an easy revenue stream for certain doctors, laboratories and pharmeceutical companies, the greater push seems to be from a desire to whatever possible to find disease. Potential liability is also an issue.
A well written book from a doctor who understands statistics.
April 13, 2021
Things to get about in the giant healthcare industry.
If you thought Big Pharma was the only sketchy player in the healthcare industry, you're in for a surprise. The author's premise is that doctors are trying "too hard" to overdiagnose - finding medical abnormalities that are not causing any symptoms of illness. This turns regular folks into patients at an alarming rate, with no clear benefit in many cases.
Thresholds for some conditions like diabetes, high blood pressure, osteoporosis, and high cholesterol have been lowered drastically in our lifetime. Presto, more patients. Statins undeniably lower a person's choesterol numbers, but is that automatically a good thing? Every medication has unwanted side effects. Is the tradeoff worth the results?
Technology has created scanning equipment that can find very small abnormalities. There's a huge upsurge in the diagnosis of thyroid cancer and prostate cancer. If the person receiving this diagnosis is alarmed and agrees to undergo surgery "to catch it early", the consequences are severe and lifelong. However, the abnormalities detected by the scans might never have caused any significant problem.
The notion of NNTT (Number Needed To Treat) was fairly new to me, so I was glad that concept was covered in the book.
I'm eager to read Dr. Welch's other book - Less Medicine More Health.
If you thought Big Pharma was the only sketchy player in the healthcare industry, you're in for a surprise. The author's premise is that doctors are trying "too hard" to overdiagnose - finding medical abnormalities that are not causing any symptoms of illness. This turns regular folks into patients at an alarming rate, with no clear benefit in many cases.
Thresholds for some conditions like diabetes, high blood pressure, osteoporosis, and high cholesterol have been lowered drastically in our lifetime. Presto, more patients. Statins undeniably lower a person's choesterol numbers, but is that automatically a good thing? Every medication has unwanted side effects. Is the tradeoff worth the results?
Technology has created scanning equipment that can find very small abnormalities. There's a huge upsurge in the diagnosis of thyroid cancer and prostate cancer. If the person receiving this diagnosis is alarmed and agrees to undergo surgery "to catch it early", the consequences are severe and lifelong. However, the abnormalities detected by the scans might never have caused any significant problem.
The notion of NNTT (Number Needed To Treat) was fairly new to me, so I was glad that concept was covered in the book.
I'm eager to read Dr. Welch's other book - Less Medicine More Health.
January 25, 2012
The biggest fault of this book is probably the tendency of the author to repeat himself rather a lot, both in explaining what he means and what he does not mean to say. But you can understand that because of the severe risks to his readers of misinterpretation of his message, or to himself if others looking to sue him were to misconstrue what he is saying.
Welch has an important point to make - I won't bore you with a restating of what that point is, as you will have read about it already to get to this review, or can do so by just clicking on the title of the book. It was a courageous and even dangerous step, no doubt, to publish his thoughts in this way, and he is doing the public a service in his work.
To one from another culture, though, an unintended sideffect of this book is shock for the reader at the unfortunate consequences of US health policy in relation to commercialisation and the allowing of drug companies to advertise directly to the public, resulting in scare tactics, insurance company's influence, and over servicing by those with an interest in using their privately owned screening equipment.
Welch has an important point to make - I won't bore you with a restating of what that point is, as you will have read about it already to get to this review, or can do so by just clicking on the title of the book. It was a courageous and even dangerous step, no doubt, to publish his thoughts in this way, and he is doing the public a service in his work.
To one from another culture, though, an unintended sideffect of this book is shock for the reader at the unfortunate consequences of US health policy in relation to commercialisation and the allowing of drug companies to advertise directly to the public, resulting in scare tactics, insurance company's influence, and over servicing by those with an interest in using their privately owned screening equipment.
March 27, 2018
I have conflicting feelings about this book. Yes, over diagnosis is a problem, but under diagnosis resulting in death/ severe problem also happens. Could a cancer or disease that wasn’t caught early and killed someone have been stopped or prevented by early detection? We don’t know that answer anymore then we know the answer to what the outcome would have been for patients who had a diagnosis because of early detection and received treatment, if they had opted out of treatment. I do think the author brings up some excellent points about how the screening guidelines don’t reflect science, which is problematic and would go a long way towards helping the situation of unnecessary intervention.
December 24, 2011
This book was really interesting considering the direction American healthcare is taking, namely spending more and more money but doing nothing to actually improve quality of life. I mainly picked it up because there was a chapter about ultrasound and fetal monitoring...turned out this was the shortest chapter but worth reading. The author had a degree in economics before going to med school so his perspective was unique. My main complaint is how frequently the author repeated catch phrases...we get it, "you've been OVERDIAGNOSED."
April 12, 2012
Underwhelming. The entire book demonstrated how over-diagnosis is harmful when seeking out diseases that are asymptomatic. Welch, also dismisses the financial incentives within the market to seek diagnosis and to treat early. Lastly, he was completely silent as to how health reform provisions (if the Supreme Court doesn't shut it down) will actually curb over-diagnosis and realign incentives towards health promotion and prevention.
October 18, 2020
Highly recommend it!! My favorite sentence in the book - “...it is difficult to promote health when actively looking for something to be wrong.”
All hypochondriacs should read this! Lots of good data driven facts.
All hypochondriacs should read this! Lots of good data driven facts.
Displaying 1 - 30 of 220 reviews