Do Physicians overstate medicine’s role in promoting health and examining the “diagnostic fake out”

The attached editorial from NEJM 6/2017 presents an interesting view on the idea of maintaining wellness.  The article raises the issue of the relationship between income and health.  It says there is a direct relationship between the two, but not for reasons one may think.  It has often been assumed that this relationship is related to increased access to medical care but what these authors suggest is that despite more care and the increased “early detection” incidences of  breast, prostate, melanoma and thyroid cancer in “wealthier” countries, the mortality rates in “poorer countries” have not risen compared to the wealthier countries.  The authors then raise the implication that much of  “preemptive care” is actually finding indolent and subclinical disease and that improvement overall in disease mortality in the rich and poor countries both is related to better treatment of active clinical disease itself and not necessarily to looking for its invisible forms earlier and in more detail.

This raises an important point for discussion.  As a believer in the importance of primary preventive medical care, there is a role for “doing ones homework” to stay healthy.  That line gets crossed though, as this article suggests, when those countries and people with “means” start to assume that and demand care (sometimes unnecessary) with the goal and assumption that dialing findings down to a subclinical stage staves off any and all future problems.  We all have seen examples where this is in fact the case;  incidentally finding an ovarian or renal cell cancer on a CT abdomen in an evaluation for non specific symptoms.  And whether or not the issue is true, true and related or true, true and unrelated is not debated.  Conversely, we have all seen examples of followup on incidental findings that leads to harmful effects.

So is it worth it to go through the “abnormal mammogram fire drill” or the relentless thyroid nodule or prostate biopsies to stay healthy versus have an adverse procedural side effect?  The answer is still not always clear for every situation and boils down oftentimes to individual patient discussion and shared decision making.  One patient can not live with the thought of the small possibility that a thyroid nodule, dcis, or abnormal psa could even remotely have a chance at causing clinical disease while others can live with that tension.  Even more troubling is what I call “the diagnostic fake out” in which the screening test raises a question, the follow up test says everything is ok and during clinical follow up the disease shows up due to a false negative on true positive scenario which is the most troubling example of why more is not always better.

The take home message is that an MRI can not always predict clinical events and that having a good discussion with one’s health care team in a trusting way is crucial.

NEJM 6/2017


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