Archive for the ‘Harriet Hall’ Category

Guest Blog: How to Choose a Doctor

Harriet Hall
Friday, March 23rd, 2012

Harriet A. Hall, MD, is a retired family physician, author and former Air Force flight surgeon who writes about medicine, complementary and alternative medicine, science, quackery, and critical thinking. She is an editor and one of the 5 MD founders of the Science-Based Medicine blog, a contributing editor to Skeptic magazine and Skeptical Inquirer, and a medical advisor and author of articles on the website Quackwatch.com. For more information on Dr. Hall, click here.

From an e-mail I received:

As a proponent of SBM, and a someone who places a high value on reason, logic and evidence, I would like to find a physician who shares this mindset.

He went on to ask how he could go about finding one.

Another correspondent was referred to a surgeon by her primary physician, and the surgeon inspired confidence until she started talking about using homeopathic arnica pills to improve healing post-op. How she could determine the technical competence of this surgeon? Was acceptance of homeopathy a reason to shed doubt on her judgment in other areas? Should she seek a second opinion?

I get a lot of inquiries about how to find a good doctor. I don’t have a good answer. I thought it might be useful to throw out some ideas that have occurred to me and hope that readers will have better ideas and will share their experiences about what has or hasn’t worked.

What Do We Want in a Physician?

  • We want a doctor who is knowledgeable and technically competent.
  • We want one who exercises good judgment.
  • We want one we can trust not to use quack diagnostic tests or quack remedies.

There are a lot of other considerations. Do you like him? Does he act like he cares about you as a person? How’s his bedside manner? Does he explain things well? Does he encourage questions? Is he authoritarian or does he treat the patient as a partner in making decisions? Is his office conveniently located? Is he booked up months in advance? Is he on your insurance plan? Is he available in an emergency? Is he reachable by phone or e-mail?

If it’s a straightforward technical matter like setting a broken bone, personalities may not matter; but in other cases (a difficult diagnostic puzzle, a chronic disease, or a psychological issue) they may matter a great deal. Sometimes through no fault of their own, a patient and doctor are simply not a good fit for each other for developing a good doctor/patient relationship. Perhaps the doctor reminds the patient of an uncle who abused her; perhaps the patient reminds the doctor of his wimpy, hypochondriacal cousin. Perhaps they have different political opinions, different religions, or different cultural backgrounds with different world views. I know an atheist who walked out of a doctor’s office when she found out he was a Christian.

What kind of doctor?

As a family physician, I’m partial to a board certified family practice doctor (FP) as primary physician; as a general rule, the FP mindset tends to be more comprehensive and practical than that of internists or specialists. A urologist sees a lot of prostate cancer and is more likely to insist on PSA screening; an FP is more likely to weigh all the pros and cons and involve the patient in deciding whether to screen.  (Of course there are exceptions.)

Consider other options besides MDs. In the US, DOs pass the same licensing exams and are trained in the same residency programs as MDs and can be considered equivalent. Physician assistants and nurse practitioners tend to be more “interested” in routine patients; many of them work in group settings with ready access to doctors when needed.

How To Find One

I have no experience in choosing a doctor. I’ve always been arbitrarily assigned to one in the military health care system. But let’s say you’ve just moved to a new city and want to find a primary physician. How could you go about it? I don’t know, because I’ve never had to do this, but here are some ideas that have occurred to me:

  1. Word of mouth. Ask friends, relatives, neighbors, and co-workers about their doctors.
  2. Ask your previous doctor. If he doesn’t know anyone in your new area, he might know someone who does.
  3. Use the Internet. Social networking sites, forums, sites that rate doctors, lists of licensing board disciplinary actions and malpractice lawsuits, the websites of doctors and the groups they work for, etc.
  4. Nurses know things. If you can find a nurse who works in a local hospital or medical center, who has had experience working with lots of different doctors, she may have a good sense of which ones are better than others, and she might have heard some pertinent grapevine gossip.
  5. Call the doctor’s office and ask if the receptionist or nurse knows if the doctor ever recommends CAM or refers to CAM providers.
  6. Check to see if the doctor’s group includes CAM providers or advertises “integrative” medicine.
  7. Ask about credentials: training, board certification, hospital privileges, etc. If you are contemplating surgery, ask about the doctor’s and the hospital’s volume and complication rates for that operation.
  8. Interview the doctor. Make a new patient appointment and tell the doctor you want to ask some questions to see if you and he are a good fit. Ask how he goes about deciding when to adopt a new drug and whether he gets his information from drug reps. Ask what he thinks about CAM. If you have a medical problem, ask what experience he has had with that problem. Watch to see if he washes his hands.
  9. If for any reason you don’t feel comfortable with a doctor, don’t hesitate to look for one you feel more comfortable with.
  10. If you have any doubts about a recommended treatment, it can never hurt to get a second opinion.
  11. Ask if the doctor reads SBM. If he answers yes, that’s a good sign! If he answers no, maybe you can get him to start reading it.

Maybe I’ve been unusually lucky. In the military health care system, I’ve been treated by MDs, DOs, PAs, NPs, and even a clinical pharmacologist; some of them were military officers, others were civilians employed by the military. I’ve seen multiple specialists in the military system and when appointments were not available in the system I’ve been referred out to civilian doctors, both primary care and specialist. None of them ever mentioned homeopathy, acupuncture, chiropractic, or energy medicine. When they talked about questionable areas, they always acknowledged that the evidence was inconclusive. The surgeon explained the biology and the statistics and then asked me to choose between breast biopsy and watchful waiting. The retinal specialist gave me a brochure about a new vitamin mixture that I “might” want to consider as a possible preventive measure for macular degeneration, but she wasn’t selling it herself or even recommending it, and she said so far there was no real evidence for prevention but only for slowing progression of established disease.

I know the medical profession includes a significant number of charlatans, of individuals who don’t really understand science, and of gullible, misguided swallowers of the Kool-Aid. But in my own anecdotal sampling of the medical profession, I haven’t come across a single health care provider who would not be acceptable to patients who are “proponents of SBM, and who place a high value on reason, logic and evidence.” I’m guessing a doctor picked at random would be more likely to agree with SBM than with Mercola. I’m hoping our readers will comment and offer practical suggestions about how best to avoid the minority of duds.

This post originally appeared on the Science-Based Medicine blog.

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The Cognitive Traps We All Fall Into

Harriet Hall
Thursday, May 26th, 2011

Harriet A. Hall, MD, is a retired family physician, author and former Air Force flight surgeon who writes about medicine, complementary and alternative medicine, science, quackery, and critical thinking. She is an editor and one of the 5 MD founders of the Science-Based Medicine blog, a contributing editor to Skeptic magazine and Skeptical Inquirer, and a medical advisor and author of articles on the website Quackwatch.com. For more information on Dr. Hall, click here.

In my recent review of Peter Palmieri’s book Suffer the Children I said I would later try to cover some of the many other important issues he brings up. One of the themes in the book is the process of critical thinking and the various cognitive traps doctors fall into. I will address some of them here. This is not meant to be systematic or comprehensive, but rather a miscellany of things to think about. Some of these overlap.

Diagnostic fetishes

Everything is attributed to a pet diagnosis. Palmieri gives the example of a colleague of his who thinks everything from septic shock to behavior disorders are due to low levels of HDL, which he treats with high doses of niacin. There is a tendency to widen the criteria so that any collection of symptoms can be seen as evidence of the condition. If the hole is big enough, pegs of any shape will fit through. Some doctors attribute everything to food allergies,  depression, environmental sensitivities,  hormone imbalances, and other favorite diagnoses.  CAM is notorious for claiming to have found the one true cause of all disease (subluxations, an imbalance of qi, etc.).

Favorite treatment.

One of his partners put dozens of infants on Cisapride to treat the spitting up that most normal babies do.  Even after the manufacturer sent out a warning letter about babies who had died from irregular heart rhythms, she continued using it. Eventually the drug was recalled.

Another colleague prescribed cholestyramine for every patient with diarrhea: not only ineffective but highly illogical.

When I was an intern on the Internal Medicine rotation, the attending physician noticed one day that every single patient on our service was getting guaifenesin.  We thought we had ordered it for valid reasons, but I doubt whether everyone benefited from it.

Recognizing warblers.

Like birdwatchers, hospitalists like Palmieri learn to identify which doctor admitted a patient. Child doesn’t appear sick; admitting diagnosis is “occult bacteremia”; patient was given an intramuscular injection of Cephotaxime in the office — oh, that must be Dr. X.

Rapid identification vs pareidolia

Humans are good at pattern recognition. This allows experienced clinicians to make rapid diagnoses, but it also allows us to see the Virgin Mary on a grilled cheese sandwich.

Rooster syndrome

Rooster crows, sun comes up; therefore rooster made sun come up. Baby had colic, was given treatment X, colic resolved; therefore X cures colic. In reality, colic resolves spontaneously by 3-4 months of age and X was useless.

Copycats

Mimicking what other physicians in the community are doing.

Availability

Choosing a drug because you have samples handy that the drug rep left.

Ulysses syndrome

Ulysses went from one adventure to another in the odyssey of returning home from the Trojan War. A false positive test can lead to a fruitless odyssey of further investigation: tests lead to more tests, maybe even invasive procedures and harm to the patient. Eventually it is realized that the patient has been healthy all along.

Unnecessary lab tests

Sometimes tests are done in a scattershot attempt to find something, anything. Palmieri’s pathologist wife directs a laboratory and frequently gets calls from doctors who have ordered an unfamiliar test and have no idea what to do when they get an abnormal result. Instead of getting an individual chemistry test, we get SMAC panels because the machine is there and it’s so convenient and cheap. With 20 tests on these panels, there is a 66% probability that at least one test will be outside normal limits on a perfectly healthy normal person.

Defensive medicine

With the present legal climate, doctors sometimes do tests or treatments with an eye to how things would look in court, rather than for the direct benefit of the patient.

Showmanship

Ordering tests to impress the patient that the doctor is being thorough and is actually doing something.

Hardwired fallibility

Our brains do not function in a rational, objective, logical way. We have built-in psychological mechanisms and defects in information processing; our brains have evolved a repertoire of tricks and shortcuts that serve us well in everyday life but that must be overcome for critical thinking and science.

Confirmation bias

Once we form a belief, we seek out evidence that confirms it and reject evidence that contradicts it. We are all biased, but by being aware of our biases we can activate a self-correcting mechanism.

Over-generalization

We form opinions about the many based on our experience of a few. We may base our idea of a disease on a patient who had an atypical presentation, or tend to avoid using a drug because of a patient who had an uncommon side effect. Radiologists who have missed a diagnosis are tempted to over-interpret x-ray findings for a time afterwards.

Anchoring

We tend to reach an early diagnosis and cling to it even when subsequent evidence doesn’t fit. We tend to accept the diagnosis of the referring physician rather than going back to square one to make up our own mind.

Diagnosis momentum

An early possibility becomes a presumptive diagnosis and gains legitimacy as it is repeated by more and more health care providers.

Framing

We seek a diagnosis within the context of how the information is presented to us. Palmieri tells about a boy who presented with “frequent throat infections.” He was referred to ENT and even had a tonsillectomy before it was discovered that he had never even had a sore throat, only unexplained fevers that had been falsely attributed to throat infections but that eventually turned out to be due to juvenile rheumatoid arthritis.

Miscommunication and assumptions

Palmieri describes a case where an ENT consultant was called in directly by the worried parents of a child hospitalized with an ear infection. He assumed that they and the pediatrician must have wanted him to put in PE tubes; otherwise there would have been no earthly reason for a consult. He had booked an OR and scheduled the patient for surgery before it became clear that the child had a first ear infection that was responding to treatment, that ENT input was unnecessary, and that PE tubes were clearly not indicated.

Algorithms

We simplify our approach to complex problems by following algorithms like “if the white count is over 15,000, give antibiotics.” This is not always appropriate. Algorithms provide a convenient framework, not an unalterable directive.

Tunnel vision

We are cautioned against thinking of zebras every time we hear hoofbeats, but we often fall into the opposite trap: we tend to fixate on the diagnoses we commonly see in our practice and not consider rare possibilities. On a recent episode of the television show “Untold Stories from the ER” there was a toddler who was refusing to walk because of leg pain. They took x-rays looking for fractures to confirm their initial diagnosis of child abuse. It turned out he had scurvy, a vitamin C deficiency that simply doesn’t occur in the 21st century US — but it did, because he was refusing all foods but oatmeal and his uneducated parents didn’t know there was anything wrong with catering to his wishes.

Conclusion

In medical school, doctors learn science but they may not learn to think like a scientist. Once out in practice, they become vulnerable to unproven claims, myths, and pseudoscience; and they are encouraged to give advice based on common sense and intuition rather than on evidence. Not just doctors but everyone needs to better understand the cognitive traps we all fall into. Since our human brains are inherently fallible, only critical thinking and good science can keep us on track. A major theme of this blog is that good science is essential for correcting our errors.

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Guest Blog: The Role of Experience in Science-Based Medicine

Harriet Hall
Thursday, April 21st, 2011

Harriet A. Hall, MD, is a retired family physician, author and former Air Force flight surgeon who writes about medicine, complementary and alternative medicine, science, quackery, and critical thinking. She is an editor and one of the 5 MD founders of the Science-Based Medicine blog, a contributing editor to Skeptic magazine and Skeptical Inquirer, and a medical advisor and author of articles on the website Quackwatch.com. For more information on Dr. Hall, click here.

Before we had EBM (evidence-based medicine) we had another kind of EBM: experience-based medicine. Mark Crislip has said that the three most dangerous words in medicine are “In my experience.” I agree wholeheartedly. On the other hand, it would be a mistake to discount experience entirely. Dynamite is dangerous too, but when handled with proper safety precautions it can be very useful in mining, road-building, and other endeavors.

When I was in med school, the professor would say “In my experience, drug A works better than drug B.” and we would take careful notes, follow his lead, and prescribe drug A unquestioningly. That is no longer acceptable. Today we ask for controlled studies that objectively compare drug A to drug B. That doesn’t mean the professor’s observations were entirely useless: experience, like anecdotes, can draw attention to things that are worth evaluating with the scientific method.

We don’t always have the pertinent scientific studies needed to make a clinical decision. When there is no hard evidence, a clinician’s experience may be all we have to go on. Knowing that a patient with disease X got better following treatment Y is a step above having no knowledge at all about X or Y. A small step, but arguably better than no step at all.

Experience is valuable in other ways. First, there’s the “been there, done that” phenomenon. Older doctors have seen more: they may recognize a diagnosis that less experienced doctors simply have never encountered. My dermatology professor in med school told us about a patient who had stumped him: she had an unusual dermatitis of her hands that was worst on her thumb and index finger. His father, also a doctor, asked her if she had geraniums at home. She did. She had been plucking off the dead leaves and was reacting to a chemical in the leaves. The older doctor had seen it before; his son hadn’t.

Then there’s what we loosely call “intuition.” It can be misleading, but it can also be a function of pattern recognition that has not risen to the level of conscious awareness. Experience can help us perceive that “something just isn’t right” about a patient or a working diagnosis. An experienced doctor may get a feeling that a patient might have a certain disease. He couldn’t justify his hunch to another doctor, but he has subconsciously recognized a constellation of findings that were present in other patients he has seen. Of course, he would still need to do appropriate tests to confirm the diagnosis, but he might do more tests and do them sooner than a less experienced doctor. This kind of pattern recognition has been called the “Aunt Tillie” phenomenon: you can spot your Aunt Tillie’s face in a crowd, but you couldn’t tell someone else how to do it. You just know Aunt Tillie when you see her. Computer face recognition is learning how to do this, but it uses measurements, not the gestalt method our brains use.

Then there’s the wisdom that (sometimes) comes with age. I’ve just been reading Marc Agronin’s book How We Age where he shows that old age is not all bad. As we get older, we are not able to accomplish mental tasks as fast, and our short-term memory declines; but there are compensations. We are more able to integrate thinking and feeling, less likely to get carried away by emotions, better able to see both sides of an issue, and better able to cope with ambiguity. We can develop more patience, acceptance, tolerance, and pragmatism in dealing with complex situations. We have a vast store of life experiences to bring to the table, helping us put things into a more realistic perspective. Wisdom is elusive: not every elder develops it. I’m sure you can all think of many counterexamples.

Medicine is an applied science, and the same science can be applied in different ways by different doctors. There are times when two science-based doctors can look at the same body of evidence and still disagree about what it really means or about what to do for a specific patient. There is room for disagreement and for different approaches. Scientific medicine is often criticized for focusing on the disease rather than on the person who has the disease. I have known patients who have turned to alternative providers because of a bad experience with a science-based doctor’s poor communication skills or “bedside manner.” We can aspire to a kinder, gentler, more personal science-based medicine where experience and improving people skills are integrated with science (a kind of “integrative medicine” that actually makes sense.)

It’s not clear whether you are better off with a young doctor or an older one. A young doctor is more likely to be up to date on the latest science; an older doctor might make better patient-centered decisions. A younger doctor might be better at tuning up your bodily vehicle; an older one might be better at helping you decide when to drive it, where to go, and how fast. A young doctor might offer the latest treatment; an older one might question whether it is really preferable to an older treatment for that particular individual, or even question whether any treatment is really necessary at all.

Conclusion:

In summary, while “in my experience” claims can be dangerous, experience does have a role to play in science-based medicine.

Disclaimer:

As an ORF (Old Retired… something) and a Medicare-card-carrying senior citizen, I am biased. I have a vested interest in thinking that I have improved with age and experience. This is an opinion piece and I can’t cite any controlled studies to support my opinions. I’m almost tempted to insert tongue firmly into cheek and say “Trust me; I’m a doctor.”

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Guest Blog: Overdiagnosis

Harriet Hall
Thursday, February 3rd, 2011

Harriet A. Hall, MD, is a retired family physician, author and former Air Force flight surgeon who writes about medicine, complementary and alternative medicine, science, quackery, and critical thinking. She is an editor and one of the 5 MD founders of the Science-Based Medicine blog, a contributing editor to Skeptic magazine and Skeptical Inquirer, and a medical advisor and author of articles on the website Quackwatch.com. For more information on Dr. Hall, click here.

Dr. H. Gilbert Welch has written a new book Over-diagnosed: Making People Sick in the Pursuit of Health, with co-authors Lisa Schwartz and Steven Woloshin.  It identifies a serious problem, debunks medical misconceptions and contains words of wisdom.

We are healthier, but we are increasingly being told we are sick. We are labeled with diagnoses that may not mean anything to our health. People used to go to the doctor when they were sick, and diagnoses were based on symptoms. Today diagnoses are increasingly made on the basis of detected abnormalities in people who have no symptoms and might never have developed them. Overdiagnosis constitutes one of the biggest problems in modern medicine. Welch explains why and calls for a new paradigm to correct the problem. 

Where to draw the line? FDR had a BP of 200/100 at the time of his re-election in 1944 and subsequently died of a stroke with a BP of 300/190. At that time, elevated BP was not commonly recognized as a problem requiring treatment. Then studies showed that the higher the BP, the greater the risk, and now everyone diagnosed with HBP is treated. That has undoubtedly saved many lives; but for someone with only a mild elevation, the risk of heart attacks and strokes is smaller and the risk of complications from treatment becomes less acceptable. So where do you draw the line and start treatment?  When the limit of 160 systolic was dropped to 140, the new definition instantly turned 13 million people with “normal” BP into patients with hypertension. Not all of those new patients were better off with treatment. Welch gives the example of an 82 year old man who was treated for mild HBP at a level where the number needed to treat for one person to benefit (NNT) was 20; he passed out from medication side effects and declined further treatment.

Changing the Rules: We’ve changed the diagnostic thresholds for many diseases, so that people who were previously classified as normal are now diagnosed with diabetes, high cholesterol and osteoporosis. Dropping the threshold of fasting blood sugar from 140 to 126 instantly created 1.6 million new diabetics, diabetics who were less likely to develop symptoms and complications and were less likely to benefit from treatment. He tells about one of his patients who was put on blood sugar-lowering medication because of the new rules and passed out while driving and broke his neck because the medication brought his blood sugar too low.

Osteoporosis: here are the numbers for treatment of decreased bone density:

  • Winners (treatment saved them from a fracture): 5%
  • Treated for naught (had a fracture anyway, despite treatment): 44%
  • Losers (treated but never would have had a fracture without treatment): 51%

Seeing too much: New technology allows us to detect abnormalities that would never have caused harm. In people without back pain, over 50% have bulging discs on MRI; 10% of asymptomatic people have gallstones on ultrasound. In patients without symptoms, what’s the value of knowing about these findings? In people with symptoms, such findings may lead to a false diagnosis.

10% of the general population and 7% of people under the age of 50 have findings of stroke on MRI. Whole body CT scanning finds abnormalities in 86% of asymptomatic people. The higher the resolution of your testing method, the more anomalies you will detect; but how many of them are important to know about? How will finding them affect health outcomes?

Prostate cancer: the harder you look, the more you find, and the smaller the cancers you detect, most of which would never have hurt the patient. Welch estimates that for every prostate cancer death avoided by screening, between 30 and 100 patients are harmed by unnecessary treatment.

In breast cancer, for every death prevented by mammography, 2 to 10 women are overdiagnosed and treated unnecessarily, 5 to 15 are diagnosed earlier without any effect on final outcome, 250-500 will have a false alarm and half of these will be biopsied. 999 out of 1000 women do not benefit from mammography. A study in Norway showed that screening resulted in 22% more diagnoses of invasive cancer; apparently some invasive breast cancers in the unscreened group had spontaneously regressed.

Other cancers: In an autopsy study, researchers determined that almost everyone has small thyroid cancers; so many that they could be considered “normal” findings. The US Preventive Services Task Force (USPSTF) recommended against screening for thyroid cancer, since it increases the diagnosis rate without affecting the death rate, and increases morbidity from unnecessary surgery and other treatments.

There is overdiagnosis of melanoma and lung cancer. For colon cancer and cervical cancer there is overdiagnosis of precancerous abnormalities.

The good news: We are learning that many, perhaps most, small cancers either regress or never progress. Spontaneous remissions may be far more common that we ever imagined. In one study, 14% of kidney cancers got smaller without any treatment. So we don’t really need to know if any cancer is present: we need to know if a cancer is present that is likely to progress and harm the patient. And so far we have no way of distinguishing which these are.

Incidentalomas are nodules or other unexpected findings noticed on imaging studies, often in body parts adjacent to the area being studied. About half of virtual colonosopies detect abnormalities outside the colon. More than 99% of the time, these are not cancers and not important to know about; but they lead to anxiety, further studies, surgeries, and complications. Protocols are being developed to follow incidentalomas suggestive of kidney and lung cancers over time rather than immediately pursuing diagnosis.

Routine electronic fetal monitoring has minuscule benefits and results in many more C-sections.

Vascular screenings: The Lifeline company and other commercial ventures offer tests direct to the public, tests that the USPSTF doesn’t recommend and that have not been shown to benefit those screened.

Genetic screening. These tests are not done for symptoms, and do not even detect signs of early disease, but just estimate future risks using inadequate data. Welch reminds us that genetics is not destiny and abnormal genes do not equal disease. The predictive value of these tests is small, and we seldom know what to do about the risk after we identify it. Low risk for a condition doesn’t mean you can’t get it, and everyone is at high risk of something.

A paradigm shift is needed, but it will be difficult to achieve for many reasons:

  • It is hard to ignore information.
  • Most people believe the more information, the better.
  • Accepted wisdom and common sense are hard to overturn.
  • Most people are convinced that it is always in people’s interest to detect health problems early, even though the data say otherwise.
  • There is a common belief that early detection is cost-effective, even though the data show it actually ends up costing more.
  • We find it hard to tolerate uncertainty.
  • Commercial interests benefit from screening and overdiagnosis.
  • Doctors fear being sued if they omit tests.
  • Anecdotes about lives saved are emotionally persuasive.

We are easily impressed by anecdotes from people who believe their lives were saved by early detection; but we don’t hear anecdotes from people who were harmed by a diagnosis of a condition that would never have hurt them, mainly because we have no way of knowing which ones they were. I am a case in point: I had a suspicious mammogram and an excisional biopsy that removed a lobular carcinoma in situ. That is not really a cancer, but more like a risk factor for cancer. Did my surgery remove a part of my breast that would have eventually developed invasive cancer and killed me, or did it uselessly remove a harmless chunk of tissue? Did it save my life or just mutilate me? I will never know.

What’s the solution? Maintaining a healthy skepticism about early diagnosis. Informed consent for screening tests, based on accurate information. Resisting over-simplified hype about the benefits of screening. Putting our efforts into prevention (exercise, smoking cessation, healthy diet, etc.) rather than pursuing early detection. Pursuing health without paying too much attention to it and without developing anxieties about it. Welch argues for not even mentioning incidentalomas on imaging reports, but I think radiologists and lawyers would object to that strategy. He says

Severe abnormalities warrant action because net benefit is likely. But the best strategy for mild ones may be to leave well enough alone, otherwise net harm is likely. In fact, it may be better not to look for them in the first place…An overdiagnosed patient cannot benefit from treatment… [but] can only be harmed.

He doesn’t offer prescriptions. He recognizes that different individuals will assess the risk/benefit ratio differently; based on the same data, some will choose to be screened and some won’t. But they deserve accurate information to base their decisions on, and this book offers a lot of good data and thought-provoking analysis.

I couldn’t help but like this book, since it says many of the same things I have been saying about screening tests , colonoscopy, osteoporosis treatment, PSA tests , not always treating , ultrasound testing , overuse of CT angiograms, genetic testing in general and in specific situations, and the pitfalls of diagnostic tests. It explains complicated concepts like lead-time bias in simple terms and spices the story with patient anecdotes. I found it a bit repetitive but that is probably an asset for driving the message home to a general audience. Both patients and doctors would benefit from reading this book and thinking about the issues it raises.

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