Is doctors' fixation on treatment making us ill?
Advances in medicine have made the impossible, possible. But an over-reliance on healthcare threatens to bankrupt the world – and make all of us sick
Jeremy Laurance is a writer on health issues. He is former health editor of The Independent and the i and has covered the specialism for more than 20 years. He thinks the harm medicine does is under-appreciated, the harm it prevents over-rated, and that cycling works better than most drugs. He was named Specialist Journalist of the Year in the 2011 British Press Awards.
Monday 30 April 2012
An NHS chief executive, who runs three hospitals with 1,500 beds, has explained why the health service is facing bankruptcy unless something is done to curb the rising tide of patient expectations.
He told how his trust in Hull had done a third hip replacement on a woman aged 90. He described a mother in her 20s who had brought her seven-year-old son to the Accident and Emergency department because he was crying after his hamster had died.
And he related how a man awaiting a shoulder replacement operation was phoned to be given the good news that his operation would be next Thursday only to respond: "Oh, I can't do Thursday. Can you make it Friday?"
They were illustrations, he said, of why the NHS was unsustainable. Combined with an ageing population and advances in medical techniques, the limits to what medicine can do, and what patients expect it to do, are ever expanding.
It is a familiar tale. But today, researchers suggest another driver of this inflationary trend which threatens to divert the entire GDP of the UK and of all developed countries across the globe into health care. It is medicine itself .
Its ability to recognise illness has been so finely honed, its tests have become so sensitive, its definitions of ill health so broad, that more and more "patients" have been sucked within its ambit. And while its capacity to heal the sick is unquestioned there is growing anxiety about its propensity to harm the healthy.
In the US as much as $200bn a year is said to be spent unnecessarily. In the UK , the tax-funded NHS and absence of financial incentives offers some protection. But in all developed economies, including the UK , too many people are being "over-dosed, over-treated and overdiagnosed", researchers writing in the online British Medical Journal say .
"Screening programmes are detecting early cancers that will never cause symptoms or death, sensitive diagnostic technologies identify "abnormalities" so tiny they will remain benign, while widening disease definitions mean people at ever lower risks receive permanent medical labels and lifelong treatments that will fail to benefit many of them," they say.
The problem is not greedy or negligent doctors. It is the reverse – an excess of enthusiasm. Doctors are trained to heal the sick and that is what they love to do. But the culture of medicine may now be getting the better of them.
The researchers from Australia and Canada cite a study which found that almost a third of people diagnosed with asthma may not have the condition, a review which suggested up to one in three screening detected breast cancers may be overdiagnosed, and the view of some experts that treatments for the bone-thinning disease osteoporosis may do more harm than good for women at very low risk of future fracture.
Widened definitions of Attention Deficit Hyperactivity Disorder have seen the number of children diagnosed escalate in recent years with a 30 per cent higher chance of being diagnosed among boys born at the beginning the school year (the youngest in class).
High cholesterol, high blood pressure, pregnant women with gestational diabetes, Asians with chronic kidney disease – in each case expanded definitions have led to thousands or millions of extra patients designated "ill".
Ivan Illich wrote in his seminal Limits to Medicine, published in 1976, that "The medical establishment has become a major threat to health."
Almost four decades on, even those who rejected that analysis may now accept that medicine is engaged in an unwinnable battle against death, pain and sickness which is threatening our humanity. The BMJ suggested in a theme issue, "Too Much Medicine", published 10 years ago, that modern health care had "sapped the will of the people to suffer reality."
Birth, ageing, sexuality, unhappiness and death had been medicalised. It cited Amartya Sen's observation that the more a society spends on health care the more likely are its inhabitants to regard themselves as sick.
Today the perils of medicalisation are still more acute. The agenda of global pharmaceutical companies, which have a clear interest in medicalising the sick, is a growing concern. But while the dangers may be better recognised, the way forward is not.
The Australian and Canadian researchers suggest fears about litigation, commercial and professional vested interests and health systems that favour more tests and treatments all drive the medicalisation of the human condition.
But a key factor is what they describe as "an intuitive belief in early detection, fed by deep faith in medical technology," which is, arguably, at the heart of the problem of overdiagnosis.
"Increasingly we've come to regard simply being 'at risk' of future disease as being a disease in its own right. Starting with treatment of high blood pressure in the middle of the 20th century, increasing proportions of the healthy population have been medicalised and medicated for growing numbers of symptomless conditions, based solely on their estimated risk of future events.
"Although the approach has reduced suffering and extended life for many, for those overdiagnosed it has needlessly turned the experience of life into a tangled web of chronic conditions."
Of course there is also much under treatment – patients diagnosed too late, or denied the best treatment. But every pound wasted on over-treatment is a pound denied to those who are under treated. In September, an international conference, Preventing Overdiganosis, is to be held at the Dartmouth Institute for Health Policy in the United States. As BMJ editor Fiona Godlee, a sponsor of the conference, points out, while the harm of overdiagnosis is becoming ever clearer "far less clear is what we should do about it."
A decade ago the BMJ called for doctors to become pioneers of demedicalisation, who would work to hand back power to patients, encourage self care and autonomy, and resist the categorisation of life's problems as medical. Their hour may finally have come.
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