If you want to avoid being diagnosed with conditions you do not have or treatments you don’t need, then you must read Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care by Dr. H. Gilbert Welch.
Dr. H. Gilbert Welch is an academic physician, a professor at Dartmouth Medical School, and a nationally recognized expert on the effects of medical testing. He has been published in the Los Angeles Times, New York Times, Washington Post, and Wall Street Journal, and has appeared on Today. Dr. Welch is the author of three previous books, including the highly acclaimed Overdiagnosed. Dr. Welch is one of my favorite physicians who is on a mission to inform and protect us from over-diagnosis and over-treatment.
So, what are the 7 assumptions?
ALL RISKS CAN BE LOWERED
Disturbing truth: Risks can’t always be lowered—and trying creates risks of its own
Example: Someone with really high blood pressure (180/110) can benefit from medical intervention, while someone with borderline high blood pressure (140/90) could be harmed from medical intervention.
IT’S ALWAYS BETTER TO FIX THE PROBLEM
Disturbing truth: Trying to eliminate a problem can be more dangerous than managing one
Example: Angioplasty (balloon procedure) for stable chest pain can be fatal in rare cases and no better than taking medications. “The accompanying editorial in the New England Journal of Medicine summed it up this way: For every 1000 patients treated with a PCI-first strategy [balloon angioplasty], approximately 2 would die, 28 would have a periprocedural myocardial infarction [a heart attack caused by the procedure], 60 to 90 would have an incremental, transient gain in health status, and 800 or more would see neither harm nor benefit.” Dr. Welch recommends managing stable chest pain with diet and exercise first rather than trying to fix it.
SOONER IS ALWAYS BETTER
Disturbing truth: Early diagnosis can needlessly turn people into patients
Example: cancer screening is supposed the catch cancer early and save lives. However, for most cancer screenings this is not the case. “There is only one cancer screening test that has definitively been proven to help people live longer: lung cancer screening in heavy smokers. Why? Because heavy smokers face a twenty-to thirty-fold increased risk of lung cancer death. In other words, for heavy smokers, lung cancer is a big component of their overall death rate.”
IT NEVER HURTS TO GET MORE INFORMATION
Disturbing truth: Data overload can scare patients and distract your doctor from what’s important
Example: more information can lead to more medical intervention, which in most cases has not led to better health. Dr. Welch mentions one study which involved severely ill patients with diabetes, lung disease, or heart disease. These patients are usually readmitted to the hospital every six months or so. “The goal of this study was to reduce that number. By more access to health care. The nurses called each patient within two days of discharge, and the physicians saw each patient within a week. The patients were given enhanced access to their doctors—including the ability to page them for a phone call…Intervention patients had 70 percent more clinic visits than controls and had an average of seven phone calls (controls had none)…In other words, the study intervention resulted in clinical cascades: more potential problems identified, more diagnostic testing, more diagnosis, more treatment, and more hospitalization. In short, the additional information produced problems.” Dr. Welch reveals similar results for enhanced intervention for patients with congestive heart failure and breast cancer. The death rate in the intervention groups was also slightly higher.
ACTION IS ALWAYS BETTER THAN INACTION
Disturbing truth: Action is not reliably the “right” choice
Example: inaction in case of an aching back is much better for the patient than action.“The researchers compared 725 patients who received back surgery with 725 patients who did not…Surgery certainly didn’t help people get back to work. Two years following the injury, 26 percent of surgical patients were working as compared to 67 percent of those who did not undergo surgery.”
NEWER IS ALWAYS BETTER
Disturbing truth: New interventions are typically not well tested and often wind up being judged ineffective (even harmful)
Example: There are more risks of trying a new medication or procedure than medication or procedure that has been in use for many years. Related to this topic is the Netflix documentary The Bleeding Edge. The Bleeding Edge is about how leading-edge medical technology that is inadequately tested but aggressively marketed to doctors and patients can cause severe long-lasting harm. Newer isn't always better.
IT’S ALL ABOUT AVOIDING DEATH
Disturbing truth: A fixation on preventing death diminishes life
Example: “We also know that some people do better with less focus on extending life. A study of 151 patients with advanced lung cancer randomized patients to receive either life-extending care or palliative care—care directed not to extending their life, but to addressing their symptoms and the stress of terminal illness. The palliative care group had less aggressive medical care: less time in the hospital, fewer trips to the emergency room, less likely to be given chemotherapy as they neared death. And they lived, on average, almost three months longer.”
In conclusion, Dr.. Welch writes:
“My motivation for writing this book rests on a firm belief: if the American public knew the full story about the benefits, harms, and uncertainties of medical care, many would choose to have less. Not less care, less medicine—meaning the interventions of testing, medication, procedures, surgeries, and devices. Obviously, I haven’t given you the whole story here. That would take multiple volumes, because there are so many dimensions to medicine…Nevertheless, moderation is still relevant to the sick. Some problems are better managed than solved. Less data can hasten recovery. Inaction can allow healing. And the old standby may be better than the next big thing. Increasingly physicians understand these things; let yours know that you do too.”
He presents each assumption with lots of humor. In fact, at times I found myself laughing out loud while reading it.
In this short video, Dr. Welch explains in his own words the 7 Assumptions.
Stay informed. Stay well!