警惕过度诊断带来的过度伤害治疗

现代科技日益发达，借助仪器人们可以看到、知道的所谓致病因素越来越多，用这来指导说服人们去治疗防病究竟是好事还是坏事？

还有对诊断出来的结果该怎样定义是属于健康范畴还是不健康范畴？书中揭示所谓的 guidlines 是由许多因素而决定的，并不是所有的决定都是真正有利于人们的健康。

推荐一本好书，连许多医生都认为它有很好的参考价值。

Overdiagnosed: Making People Sick in the Pursuit of Health

有时间还会详谈这本书，觉得它写得非常好。书名有些吸眼球，但内容还是非常客观。此书详细分析了各种检查的利弊和怎样对待检查结果。书中还揭示了对外宣传的许多风险的评估和所谓治疗意义中的种种猫腻、一些医疗介入手段的真正预防效果和伤害。

有一个例子我还记得：一位做过 1 万人全身 CT Scan 体检的医生说他只发现一个“正常“的人（下面普通读者的书评中引述数据不对）。现在利用基因技术发现致病的基因会越来越多，人们都需要去针对这些致病基因去治疗来预防疾病吗？有没有更好的途径防病？

先贴一位读者对此书的评述，以后我还会针对性介绍这本书的内容。

161 of 162 people found the following review helpful

Good Insights -

By Loyd E. Eskildson HALL OF FAME on January 22, 2011

Format: Hardcover

Conventional wisdom is that more diagnosis, especially early diagnosis, means better medical care. Reality, says Dr. Gilbert Welch - author of "Overdiagnosed," is that more diagnosis leads to excessive treatment that can harm patients, make healthy people feel less so and even cause depression, and add to escalating health care costs. In fact, physician Welch believes overdiagnosis is the biggest problem for modern medicine, and relevant to almost all medical conditions. Welch devotes most of his book to documenting his concerns via examples of early diagnosis efforts for hypertension, prostate cancer, breast cancer, etc. that caused patient problems.

Welch provides readers with four important and generalizable points. The first is that, while target guidelines are set by panels of experts, those experts bring with them biases and sometimes even monetary incentives from drug-makers, etc. Over the past decades many target levels have been changed (eg. blood pressure, cholesterol levels, PSA levels), dramatically increasing the number classified as having a particular condition. (Welch adds that prostate cancer can be found at any PSA level - about 8% for those with a PSA level of 1 or less, over 30% for those with a level exceeding 4; most are benign.)

The second is that treating those with eg. severe hypertension benefits those patients much more than treating those with very mild hypertension or 'prehypertension;' the result is treating those with lesser 'symptoms' can easily cause new problems that outweigh the value of the hypertension treatment.

The third is that Welch believes it is usually more important to treat those with disease symptoms (eg. pain) than those without. For example, almost 70% of men 60-69 have prostate cancer, as well as about 10% of those aged 20-29 - a large number are better left untreated because their particular cases involve a very slow-growing form and the side-effects of treatment outweigh the benefits. Welch also reports that a study of over 1,000 symptom-free people that underwent total-body CT screens found 86% had at least one detected abnormality, with an average of 2.8. Many of these abnormalities later disappear (some cancers disappear), while others grow very slowly, if at all. Providing unneeded treatment subjects patients to unneeded pain, risk of adverse outcomes (including death), and unneeded expense.

Examples: Welch cites the example of a mildly hypertensive older man that he treated; unfortunately, while shoveling snow the individual passed out from a combination of sweating and the diuretic prescribed for his high blood pressure. Welch discontinued the man's medication. Similarly, Dr. Welch treated a patient with mild diabetes - the result was she fainted from low blood sugar (the level fluctuates around a mean) while driving just after a meal and was severely injured in an accident. Dr. Welch discontinued her medication as well.

Meanwhile, at the same time that a number of target guidelines have been tightened, the availability and capability of scanning and other detection devices to find abnormalities has also increased. For example, since the early 1990s, Welch tells us that the Medicare per capita use of head scans has doubled, the rates of abdominal scans have tripled, chest scans quintupled, brain MRI rates quadrupled, etc. New biopsy methods for detecting prostate cancer (eg. sampling from 18 points rather than 12 or fewer) also increase the number of benign 'false-positive' diagnoses, probably much more so than true positives.

Why is there so much testing? Dr. Welch attributes it to well-meaning disease advocacy groups, testimonials (eg. ex-Senator Dole regarding his prostate cancer), quality-improvement efforts that include testing as one of their criteria, malpractice awards, hospital/specialist/drug company marketing (beware of these, says Welch), and honest disagreement over its value. He's also concerned about what lower-cost DNA testing will add to the overdiagnosis problem, contending that everyone's genes will reveal heightened susceptibility to some ailments and diseases, with little that can be done despite the knowledge. The author would probably also be concerned about new Medicare requirements to provide a battery of up to 45 medical tests ("The Wall Street Journal" - 1/18/2011). That article also reports that a "New England Journal of Medicine" review of hundreds of preventive-care studies showed that fewer than 20% saved money.

Bottom-Line: Dr. Welch raises an important topic for improving health care while reducing costs. His main recommendation, more data from clinical trials showing the outcomes of choosing one diagnosing standard/method over another, is important and appropriate.

Editorial Reviews

From Booklist

*Starred Review* Health policy expert Welch’s assertions about the benefits of some of modern medicine’s most popular diagnostic screening tools are unlikely to ingratiate him with many people. He claims that overdiagnosis “is the biggest problem posed by modern medicine,” and backs that assertion up with a barrage of facts, charts, and graphs. This is information, he says, that is downplayed or simply ignored by individuals and groups promoting the notion that earlier diagnosis—whether for prostate cancer or diabetes—translates to better health. Indeed, Welch says, just the converse is more often true. In an overwhelming number of circumstances, early diagnosis turns healthy, asymptomatic people into patients who require a variety of medical interventions with no benefit, even exposing them to unnecessary harm. Worse, overdiagnosis can render perfectly healthy people uninsurable. Furthermore, instead of lowering health-care costs, all those scans, screenings, and tests actually raise costs by overtreating people who will never benefit from said treatment. His point is that both physicians and patients need to be skeptical and understand all the data (pro and con) surrounding prescreening for possible illness. Welch speaks his truth with a frankness and clarity scant found in today’s hysteria over medical prescreening. --Donna Chavez --This text refers to the Hardcover edition.

Review

“Very insightful and engaging.”—Dennis Rosen, The Boston Globe

“One of the most important books about health care  in the last several years.”—Cato Institute 

"One of the big strengths of this relatively small book is that if you are inclined to ponder medicine's larger questions, you get to tour them all. What is health, really?... In the finite endeavor that is life, when is it permissible to stop preventing things? And if the big questions just make you itchy, you can concentrate on the numbers instead: The authors explain most of the important statistical concepts behind evidence-based medicine in about as friendly a way as you are likely to find."—Abigail Zuger, MD, The New York Times

"Overdiagnosed —albeit controversial—is a provocative, intellectually stimulating work. As such, all who are involved in health care, including physicians, allied health professionals, and all current or future patients, will be well served by reading and giving serious thought to the material presented."─ JAMA

“Everyone should read this book before going to the doctor! Welcome evidence that more testing and treatment is not always better.”─ Susan Love, MD, author of Dr. Susan Love’s Breast Book
 
“This book makes a compelling case against excessive medical screening and diagnostic testing in asymptomatic people. Its important but underappreciated message is delivered in a highly readable style. I recommend it enthusiastically for everyone.”─ Arnold S. Relman, MD, editor-in-chief emeritus, New England Journal of Medicine, and author of A Second Opinion: Rescuing America’s Health Care 
 
“This stunning book will help you and your loved ones avoid the hazards of too much health care. Within just a few pages, you’ll be recommending it to family and friends, and, hopefully, your local physician. If every medical student read Overdiagnosed, there is little doubt that a safer, healthier world would be the result.”─ Ray Moynihan, conjoint lecturer at the University of Newcastle, visiting editor of the British Medical Journal, and author of Selling Sickness
 
“An ‘overdiagnosis’ is a label no one wants: it is worrisome, it augurs ‘overtreatment,’ and it has no potential for personal benefit. This elegant book forewarns you. It also teaches you how and why to ask, ‘Do I really need to know this?’ before agreeing to any diagnostic or screening test. A close read is good for your health.”─ Nortin M. Hadler, MD, professor of medicine and microbiology/immunology at University of North Carolina at Chapel Hill and author of Worried Sick and The Last Well Person
 
“We’ve all been made to believe that it is always in people’s best interest to try to detect health problems as early as possible. Dr. Welch explains, with gripping examples and ample evidence, how those who have been overdiagnosed cannot benefit from treatment; they can only be harmed. I hope this book will trigger a paradigm shift in the medical establishment’s thinking.” —Sidney Wolfe, MD, author of Worst Pills, Best Pills and editor of WorstPills.org

About the Author

Dr. H. Gilbert Welch is a renowned authority on the effects of medical screening who has appeared on The Today Show, CNN, NPR, and in the New York Times andWashington Post. He and his coauthors, Dr. Lisa M. Schwartz and Dr. Steven Woloshin, nationally recognized experts in risk communication, are professors at the Dartmouth Institute for Health Policy and Clinical Practice. 

Excerpt. © Reprinted by permission. All rights reserved.

My first car was a ’65 Ford Fairlane wagon. It was a fairly simple—albeit
large—vehicle. I could even do some of the work on it myself. There was a lot
of room under the hood and few electronics. The only engine sensors were a
temperature gauge and an oil-pressure gauge.

Things are very different with my ’99 Volvo. There’s no extra room under
the hood—and there are lots of electronics. And then there are all those little
warning lights sensing so many different aspects of my car’s function that
they have to be connected to an internal computer to determine what’s wrong.
Cars have undoubtedly improved over my lifetime. They are safer, more
comfortable, and more reliable. The engineering is better. But I’m not sure
these improvements have much to do with all those little warning lights.
Check-engine lights—red flags that indicate something may be wrong
with the vehicle—are getting pretty sophisticated. These sensors can identify
abnormalities long before the vehicle’s performance is affected. They are
making early diagnoses.

Maybe your check-engine lights have been very useful. Maybe one of
them led you to do something important (like add oil) that prevented a much
bigger problem later on.

Or maybe you have had the opposite experience.

Check-engine lights can also create problems. Sometimes they are false
alarms (whenever I drive over a big bump, one goes off warning me that
something’s wrong with my coolant system). Often the lights are in response
to a real abnormality, but not one that is especially important (my favorite is
the sensor that lights up when it recognizes that another sensor is not sensing).
Recently, my mechanic confided to me that many of the lights should
probably be ignored.

Maybe you have decided to ignore these sensors yourself. Or maybe
you’ve taken your car in for service and the mechanic has simply reset them
and told you to wait and see if they come on again.

Or maybe you have had the unfortunate experience of paying for an
unnecessary repair, or a series of unnecessary repairs. And maybe you have
been one of the unfortunate few whose cars were worse off for the efforts.

If so, you already have some feel for the problem of overdiagnosis.

I don’t know what the net effect of all these lights has been. Maybe they
have done more good than harm. Maybe they have done more harm than
good. But I do know there’s little doubt about their effect on the automotive
repair business: they have led to a lot of extra visits to the shop.

And I know that if we doctors look at you hard enough, chances are we’ll
find out that one of your check-engine lights is on.

A routine checkup

I probably have a few check-engine lights on myself. I’m a male in my midfifties.
I have not seen a doctor for a routine checkup since I was a child. I’m
not bragging, and I’m not suggesting that this is a path others should follow.
But because I have been blessed with excellent health, it’s kind of hard to
argue that I have missed out on some indispensable service.

Of course, as a doctor, I see doctors every day. Many of them are my
friends (or at least they were before they learned about this book). And I can
imagine some of the diagnoses I could accumulate if I were a patient in any
of their clinics (or in my own, for that matter):

• From time to time my blood pressure runs a little high. This is particularly
true when I measure it at work (where blood pressure machines are
readily available).
Diagnosis: borderline hypertension

• I’m six foot four and weigh 205 pounds; my body mass index (BMI) is 25.
(A “normal” BMI ranges from 20 to 24.9.)
Diagnosis: overweight

• Occasionally, I’ll get an intense burning sensation in my midchest after
eating or drinking. (Apple juice and apple cider are particularly problematic
for me.)
Diagnosis: gastroesophageal reflux disease

• I often wake up once a night and need to go to the bathroom.
Diagnosis: benign prostatic hyperplasia

• I wake up in the morning with stiff joints and it takes me a while to loosen
up.
Diagnosis: degenerative joint disease

• My hands get cold. Really cold. It’s a big problem when I’m skiing or
snowshoeing, but it also happens in the office (just ask my patients). Coffee
makes it worse; alcohol makes it better.
Diagnosis: Raynaud’s disease

• I have to make lists to remember things I need to do. I often forget
people’s names—particularly my students’. I have to write down all my
PINs and passwords (if anyone needs them, they are on my computer).
Diagnosis: early cognitive impairment

• In my house, mugs belong on one shelf, glasses on another. My wife
doesn’t understand this, so I have to repair the situation whenever she
unloads the dishwasher. (My daughter doesn’t empty the dishwasher, but
that’s a different topic.) I have separate containers for my work socks,
running socks, and winter socks, all of which must be paired before they
are put away. (There are considerably more examples like this that you
don’t want to know about.)
Diagnosis: obsessive-compulsive disorder

Okay. I admit I’ve taken a little literary license here. I don’t think anyone
would have given me the psychiatric diagnoses (at least, not anyone outside
of my immediate family). But the first few diagnoses are possible to make
based solely on a careful interview and some simple measurements (for example,
height, weight, and blood pressure).