Having followed the debate on the cost of healthcare for some years, I was intrigued to see on our new book shelves. Dr. Welch is a practicing physician and a professor at Dartmouth Medical School. He has written two previous books, one of which (Overdiagnosed) we also own. I’m checking that one out next!
The book is broken down into seven chapters, based on often made, but erroneous, assumptions. We, as medical consumers, make assumptions based on incomplete, overstated, and just flat out wrong information and “common sense.” Making healthcare decisions based on bad assumptions leads to wasted money, time, and effort and (far too often) bad outcomes for our health. At least that’s what Dr. Welch is telling us and I found his arguments persuasive.
Assumption 1, that “All risks can be lowered,” causes us to scare ourselves silly on a regular basis when we read (and believe) all the medical news out there. Coffee will kill you. Eggs are deadly. Apple juice and rice are lethal. Too much (or too little) sleep causes premature death. All these, and far more, are among the things constantly being touted as risks for illness and/or death. Some of these alarms are later downplayed or refuted. Have some coffee with those eggs, they tell us this week. Problem is, even if there are risks associated with something, what degree of risk are we talking about? Some things have well-known, documented, statistically significant risks. Smoking is a prime example. Smoking is a known cause of lots of cancer and heart disease. Stopping smoking is one of the best things you can do for your health (aside from not starting). It’s well established that some amount of exercise is good for your health. Controlling really high blood pressure or extreme diabetes are no-brainers. Wearing a seat belt? Darn good idea. These are risks that are real and that can be controlled. Many other risks are maybe not so much a risk as the media would scare you into believing, and trying to control them may do more harm than good. What is often overlooked is whether the benefit of risk reduction outweighs the cost, both financially and in outcome. There are always risks associated with medical interventions. You might be allergic to a drug or simply suffer more of those lovely side effects they race through on the television ads. “Including death” is often one of those “side effects” mentioned. Even controlling known risks can have bad consequences. Medications taken to control high blood sugar can cause low blood sugar, which can lead to unconsciousness or worse. That’s not to say you should ignore diabetes, but it may be better to ask your doctor about trying to lower it some, through diet and exercise, and look at A1C levels to determine what your blood sugar is over time than to monitor closely and try for tight control. For those with Type-2 diabetes, that may be the wave of the future—moderate control over long term blood sugar with less intervention and less frequent (stressful) monitoring. Dr. Welch points out that he was responsible for a patient’s broken neck because he diagnosed him with diabetes, and tried (as was the only practice at that time) for very tight control. Testing had shown treatment was working, but one day the control got too tight, his blood sugar got too low, and he passed out and crashed his car. He survived, and later testing showed his blood sugar was only moderately elevated and Welch stopped his medication and kept an eye on it. No more loss of consciousness, no diabetic coma, no problem.
Assumption 2 is that “It’s always best to fix the problem.” Well, maybe not. If you’re a man of a certain age and are diagnosed with prostate cancer (as a prime example), the best thing to do may be “watchful waiting.” By age 60, over half of men autopsied (who did not die of prostate cancer) were found to have some degree of prostate cancer. Prostate cancer is often very slow growing, and treatment can cause severe side effects. It may well be, in many cases, better to watch and wait than to “fix the problem” immediately, particularly for illnesses that may progress slowly and for which treatment is problematic.
Assumption 3, “Sooner is always better” builds on that, while Assumption 4, “It never hurts to get more information” ain’t necessarily so. For Assumption 5, “Action is always better than inaction” fleshes out more of the subject of Assumption 2.
Assumption 6, “Newer is always better,” is fairly obvious if you think about it. There have been numerous drugs introduced in the past few years that have been pulled off the market because it turned out they killed people.
Assumption 7, “It’s all about avoiding death,” reminds us all that death is inevitable and we need to consider quality of life versus quantity. If treatment will only (probably) add a short time to your life and will (probably) make you sick or keep you in the hospital, you should weigh the risks and rewards. Perhaps you want as much time as possible, period. Perhaps you would rather have more quality than quantity of life. Whichever you would prefer, you need to have the risks and options explained and your wishes carried out without the medical professionals making assumptions and proceeding accordingly. It’s your life.
To sum up, I found the book very interesting in an intellectual way (sort of a medical Freakonomics) on one hand and, on the other hand, a much more visceral read about life, death, and what comes along with each. There are lots of personal stories, and nothing excessively academic and the author writes with a good deal of humor, as well. Interesting and thought-provoking, and I’m off to read Overdiagnosed!