A nationally recognized expert describes seven widespread assumptions that encourage excessive, ineffective, and sometimes harmful medical care—for readers of Overdiagnosed and Malcolm Gladwell
You might think the biggest problem in medical care is that it costs too much. Or that health insurance is too expensive, too uneven, too complicated—and gives you too many forms to fill out. But the central problem is that too much medical care has too little value.
Dr. H. Gilbert Welch is worried about too much medical care. He doesn’t deny that some people get too little medical care—rather that the conventional concern about “too little” needs to be balanced with a concern about “too much”: too many people being made to worry about diseases they don’t have and are at only average risk to get; too many people being tested and exposed to the harmful effects of the testing process; too many people being subjected to treatments they don’t need or can’t benefit from. The American public has been sold the idea that seeking medical care is one of the most important steps to maintain wellness. Surprisingly, medical care is not, in fact, well correlated with good health. More medicine does not equal more health; in reality the opposite may be true.
In Less Medicine, More Health , Dr. Welch pushes against established wisdom and suggests that medical care can be too aggressive. Drawing on his twenty-five years of medical practice and research, he notes that while economics and lawyers contribute to the excesses of American medicine, the problem is essentially created when the general public clings to these powerful assumptions about the value of tests and treatments—a number of which are just plain wrong.
By telling fascinating (and occasionally amusing) stories backed by reliable data, Dr. Welch challenges patients and the health-care establishment to rethink some very fundamental practices. His provocative prescriptions hold the potential to save money and, more important, improve health outcomes for us all.
As an emergency physician my job mostly involves reassuring people that they DON'T have a serious illness when they're worried that they DO. Many simply aren't satisfied unless I've ordered a lot of "tests." This is not simply my opinion--many studies bear this out as true. Doing less is very difficult when all the incentives point to doing more. I believe over-testing, over-diagnosis, and over-treatment are the real causes behind America's abysmal track record. We spend nearly twice as much per capita as other nations to far worse outcomes. The wealthy receive too much testing and the poor too little. Dr Welch makes a great case for less medicine and how this often leads to better health outcomes. One thing for certain is that the more doctors reside within a community the more that community spends on healthcare--but mostly to no better outcomes. Although I found Dr Welch's style a little too folksy and self-deprecating for my tastes, the message is spot on. A good read for both doctors and patients.
Blurb on the cover of this book by Atul Gawande, MD, author of Being Mortal: “Read this book. It is smart, witty, wonderfully written, and above all wise.”
A few years ago, I read Dr. Welch’s other book, Overdiagnosed: Making People Sick in the Pursuit of Health, and was instantly a fan. This one is as good, if not better, and I am here to gush about how interesting and important these books are. Dr. Welch is a primary care physician and researcher in New England who is on a quest to draw attention to some of the problems with the current healthcare system in the U.S., particularly the over-emphasis on “preventive” screenings, drugs, and procedures that, when directed to people who are well and feeling fine, may in some cases do more harm than good. Some risks matter and should be addressed; the rest is noise. He pleads for a more judicious approach than subjecting everyone to every option available and for balancing the risk and benefits of screenings and medical interventions. This is something I have believed in for a long time, long before I found these books, but Dr. Welch validated my beliefs and brought receipts.
The language is not too science-y for the non-clinician reader, but he uses data, as well as explanations of anatomy, biology, and the mechanisms of disease and medical devices, etc., to prove his points in a fairly clear manner. He delves into interesting concepts such as how data differs from information, which differs from knowledge, which differs from wisdom. He also uses plenty of patient stories and case studies in a conversational tone to illustrate some of the pitfalls of unnecessary interventions.
In spite of the common messaging, more is not necessarily better when it comes to medicine. Even screenings, which are often touted as harmless, can lead to undesirable unintended consequences, including false alarms (which lead to more tests and more procedures), completely unnecessary anxiety, over-diagnosis, over-treatment, and a general tendency, the U.S. healthcare system being what it is, to do more and more in a cascade that keeps people on a testing and procedure treadmill that is hard to exit once it gets going. So it’s important to have sufficient information to make decisions about one’s health that are in keeping with an individual’s situation and preferences. This book opens a window onto broader perspectives that can empower people to be better advocates for themselves and their medical needs.
Dr. Welch makes no money from his books. The royalties go to charities in Vermont and New Hampshire that provide direct services to the disadvantaged: shelters, food distribution agencies, or organizations that repair homes or vehicles. His aim is simply to get the word out and expose people to some of the lesser-known realities of the system that can lead to more knowledge for the patient and better joint decisions with their physician.
I wish more doctors – all doctors, really – would read this book. And even if you think this is a topic that does not interest you, I would also highly recommend it for anyone who might be a patient in the future. Which is, of course, potentially all of us.
I once had a wonderful physician who used to tell me, "I'll give you my medical-legal opinion and then I'll tell you what I think." She taught me to always ask doctors to think a bit more about their recommendations. If the test is positive, what would we do differently? What are the possible secondary consequences? What happens if we do nothing?
Dr. Welch, a primary care physician, has given us a thoughtful but radical critique of common medical practices, based on epidemiological statistics. In other words, he looks at data on outcomes of medical interventions to find out whether common medical practices contribute to or diminish overall health and well-being.
The most controversial claims that Dr. Welch makes are about the wisdom of foregoing routine medical screening tests including mammograms, colonoscopies, and PSA screenings. He cites epidemiological studies that show no improvement in overall outcomes for those who are screened versus those who are not. This is counterintuitive because the medical community has stressed for years that early detection is key to surviving cancer. Empirically, data shows few marginal advantages to early screening. So why not be screened on the off chance you would gain from it? Welch points out that screening carries substantial health costs as well because it leads to treatments that may diminish quality of life while failing to deliver the promised quantity of life. Worst of all, most treatments have side-effects that require further treatment, ultimately resulting in cascades of medical problems.
While Welch is highly critical of many common medical interventions, he is not dismissive of medicine. He finds common tests like blood pressures quite useful when understood in appropriate context. Many people develop "white coat" high blood pressure, that is high pressures due to anxieties associated with being in a medical clinic. If treated aggressively, blood pressure can plummet causing confusion and blackouts. Thus, to be useful, blood pressures must be monitored, not assumed to be accurate at a single moment in time.
I found Welch's arguments persuasive. More medicine does not seem to produce more health in many cases. I doubt I will submit to another mammogram without cause to believe something is wrong. The value in this book is the information that allows readers to make better health choices through evidence-based medicine. Welch is an empiricist, not a demagogue. The seven assumptions about health that he debunks are well worth consideration when making health choices.
This is an important book because it encapsulates much that is wrong with the way we think about health. It echoes what Atul Gawande has to say about end of life care, that quality of life should count in our definition of health. Medical intervention often trades off quality of life in exchange for a few more weeks or months of survival. Whether this trade-off is worthwhile should be a thoughtful choice, not a foregone conclusion.
الكتاب الثاني للدكتور وليش بعد كتابه Overdiagnosis. هنا يعرض لفكرة أن حياتنا أصبحت خاضعة للطب أكثر من اللازم، حيث يحاول تفكيك سبعة مفاهيم أساسية مغلوطة منتشرة بين الأطباء والمرضى على السواء.
فعلى سبيل المثال مفهوم: الجديد دائماً أفضل. حيث يستعرض من خلال عدة أمثلة على عقارات وأدوات طبية لم تكن بالضرورة كذلك، بل كانت أسوأ من سابقتها. كذلك مفهوم: لا ضرر من معرفة معلومات أكثر. حيث يستعرض للتوجه الطبي لمعرفة أكبر قدر من المعلومات من خلال طلب العديد من الفحوصات. والتي قد لا تفيد بل تضر أحياناً حينما يتم اتخاذ اجراءات طبية بناءاً عليها. أيضاً مفهوم: من الأفضل دائماً اصلاح المشكلة. حيث يستعرض للنموذج الطبي المسيطر عند الأطباء في اصلاح المشاكل دائماً. وحتى وإن أدت وسيلة الاصلاح لالحاق الضرر بالمرضى.
عن طريق استعراض طويل لأمثلة فردية ودراسية علمية على كل مفهوم. ومن ثم يقوم بتصويب تلك العدسة من خلال أمثلة حديثة أو اقتراحات علمية.
وفي النهاية يخلص دكتور وليش إلى حاجاتنا لتقليل التطبيب وسيطرته على حياتنا من جهة، وتوسيع مفهوم الصحة من جهة أخرى.
About a year ago, I found the book "Overdiagnosed: Making People Sick in Pursuit of Health". Upon hearing the audiobook I felt I had finally found an author who shared my opinion on the screening and diagnoses made in health care.
This new book by Welch seems to be directed to the general population. It is less detailed and technical, and the tone is lighter. However, I would recommend it also to all who provide health care.
The author discusses many of the myths that patients and carers have in relation to health. I know that many will refuse to accept the arguments presented, but the truth is that the diagnostic and therapeutic aggressiveness hasn’t necessarily contributed to better health outcomes.
As a family doctor, I notice that many patients are uncomfortable when I explain the pros and cons of a screening or treatment, when I explain that the new medicaments aren’t always the best option, when I ask them to give their body some time to recover, or when I propose a joint decision. People are still accustomed to a paternalistic medicine and look askance at anyone who doesn’t pass multiple exams or doesn’t always give a medication. By the time I explain that a particular test that they want is not appropriate, I notice that they feel like I had devalued their symptoms or I just want to save money. This approach obviously requires that I spend a long time justifying a particular medical decision. It is also necessary to adjust the patient’s expectations, as well as the physician’s expectations. It is a long and hard road, but so far I can say it is worth it.
The message brought by Welch in "Less Medicine, More Health" is the battle of many doctors, though not at all covered in the course of medicine (at least in my country). This is a book I recommend to all, so that all decisions are the most informed possible and the results more satisfactory.
I thoroughly enjoyed reading this very sensible discussion about interacting with the healthcare system in such a way that you avoid having your life become unnecessarily medicalized. An once of "prevention," in the form of screenings and tests for the asymptomatic, all too often leads to worse health outcomes rather than better ones. I recommend it.
This book caught my eye because the title sums up my own philosophy in a nutshell. With eloquence and humour Dr.Welch states the case for his belief that too many people are being made to worry about diseases they don't have and are at only average risk to get, too many people are being tested and exposed to the harmful effects of the testing process, and too many people are being sub jected to treatments they don't need or cannot benefit from. Below I list the seven assumptions Dr. Welch covers that drive too much medical care, and after each one I give a short quote from the chapter. 1) All risks can be lowered. "It's not possible to eliminate all risk - nor is it desirable. And with medical care trying creates risks of its own." 2)It's always better to fix the problem. "Fixing things is a bit of a gamble. There's a chance that it makes you a whole lot better, but there's also a chance it makes you a whole lot worse." 3)Sooner is always better. "When considering screening, recall the general principles. Many must be involved to potentially benefit a few. Harms are expected; false alarms are a certainty; some degree of overdiagnosis - and overtreatment - is likely." 4) It never hurts to get more information."More clinical data not only can create anxiety for patients, they can also initiate cascades that lead to unneeded medical care." 5) Action is always better than inaction. "But the reality is that the human body can heal and that all of our actions have unintended consequences. Thus, inaction can often be the preferred course." 6) Newer is always better. "In medical care too often the word 'new' is associated with the word 'improved' - when it would be better associated with the word 'untested' ". 7) It's all about avoiding death. "Disturbing truth: A fixation on preventing death diminishes life." This really is a fascinating book and well worth reading, even if you - or maybe especially if - you think you will disagree.
As a retired lab tech grunt who toiled away trying to do justice to the tons of specimens submitted for long lists of tests that are ordered by Physicians, I can assure you that more testing is definitely not leading to better care. Welch is a wise physician and I hope his critical view of testing clears the benches of many of those stupid, trivial test requests that we get in the lab. Cut out the cover-your-butt off-the-wall test requests and all of us will benefit-particularly the patient who needs careful timely diagnostic testing. This is a great book.
Practical and convincing information for the layperson about complicated medical issues. Welch, a GP, addresses such question as: (1) Under what conditions is health screening valuable? (2) When is a "risk factor" worth paying attention to? (3) When is medical treatment likely to be helpful and when is it likely to be harmful? Etc.
I checked this book out of the library to read it, but am thinking I should buy it, to have on hand as a sanity check and confidence builder when up against medical authorities. I liked it that much.
I loved this book. I have been a practicing Optometrist for 41 years and I learned a lot. Dr. Welch wrote this book for the general public but I would recommend it be read by everyone in health care. I am from the little town in western Pennsylvania -Donora - that had the killer smog in 1948 that he references in the book so this resonated a little more with me. Primarum non nocere-"first do no harm" is the mantra of all in health care. But as Dr. Welch painfully points out," the only Doctor that doesn't do harm is the one who doesn't see patients". This book is well worth your time.
Поради нарастващия натиск от търсене на съдебна отговорност и поради желанието все пак да могат да изхранват семействата си съвременните лекари са склонни да прекаляват с медицинските грижи. Често пациентите се подлагат на ненужни изследвания, ненужни интервенции и ненужно лечение за болести, които нямат или с които могат спокойно да живеят. За да докаже това Dr. Gilbert Welch прави 7 допускания:
1.Не всички рискове за здравето могат да се избегнат. А и няма нужда. Дори избягването на някои рискове може да доведе до появата на нови такива. Може би има корелация между консумирането на шоколад и риска от захарен диабет, но тя е доста спорна и ниска. Ето защо няма нужда да се отказваме от шоколада като цяло.
2.Има медицински състояния, които е по-добре да не бъдат лекувани (особено инвазивно).
3.Невинаги ранната диагностика е добра идея. Тази точка беше доста неубедителна и подкрепена с доста неубедителни аргументи. Особено много не съм съгласна с отричането на скрининга.
4.Прекалено много медицински сведения за пациента са ненужни и само затрудняват диагностицирането. Като основен пример са дадени генетичните изследвания, в които често се установяват отклонения от нормата без да можем да ги тълкуваме правилно.
5.Действието невинаги е по-добро от бездействието. Често лекарите забравят, че тялото има способността да се самолекува. Изкуството на медицината е да знаеш кога не трябва да правиш нищо.
6.Новото в медицината обикновено е по-неефективно от старото, защото е по-зле изпитано.
7.Медицината не на всяка цена трябва да се стреми към избягване на смъртта, но на всяка цена трябва да се стреми към подобряване на качеството на живота. Често лекарите забравят, че не е важно само животът да се поддържа, а има значение и какъв е животът. Пациентът има право да сложи край на страданията си без той и близките му да бъдат осъждани.
Давам 3 звезди заради изключително скучния стил на писане на автора.
I’m one of those people who had a screening mammogram that lead to a biopsy, then a mastectomy and then chemo. I had an aggressive cancer (a rabbit in the author’s analogy) and treatment almost certainly saved me. And yet... I have come to believe that there is indeed such a thing as too much testing. And, after reading Atul Gawande’s “Being Mortal,” I have given a lot of thought about what I’d do if my cancer came back - what treatment I’d consent to and what would be a hard no. This book reinforces my feeling that it’s not just okay but preferable to take charge as a patient and decline what feels unnecessary or wrong for myself. I have slot of respect for medicine and medical professionals, but I also know that doctors often shorten the first part of Hippocratic oath from “First, do no harm” to”First, do.” Just because a test can be done, doesn’t mean it should be.
This review was written for LibraryThing Early Reviewers. 4.5 stars.
Lately I have been taking the time to read a few books on health/nutrition every year so that I am better informed about decisions I make for my well being. This book was a worthy first choice for 2015.
The author basically makes the case for less medical intervention for non-acute medical care and end of life situations. I've always thought that nature more or less knows best, and people need to get out of the way of nature when it comes to health issues. To me medication is in general a bad idea. Don't get me wrong - if I get a bad headache or am sore from exercise, I'll still take some ibuprofen, and if I am sick I'll still take cold medicine to sleep, but I won't make a habit of it. But I try to think about what is wrong with me and why, and if there is something I can change to avoid taking something in the first place. I think that too often taking a pill can be taking the easy way out when a behavioral change is what is really needed for your health. I take a look at my own mother as an example - she had been taking statins for high cholesterol for several years. Doctors recommend them for just about everyone these days, saying they help and do no harm. Well my mother - like MANY people - was suffering from significant leg pain and fatigue. Me and my sister convinced her to improve her diet and exercise and talk to her doctor about getting off statins. He agreed to give it a try - and she is feeling a lot better, and eating better and going to the gym several times a week for the first time in her life. Honestly, how much longevity would you be willing to trade at 72 at the price of fatigue and leg pain for the rest of your life? It's not a question with a clear answer, but it is one worth asking and looking for what the actual answer is. One of the main points the author makes is that there IS no answer for everyone. Some folks say 5 years wouldn't be worth leg pain, others would trade it for 5 days. Find out what the real benefit is statistically likely to be for you, and decide what choice is right for you.
The book also brings up the issue around whether or not ignorance really is bliss sometimes. These days you can go on the internet, and quickly convince yourself that a pimple is terminal cancer. Self prognosis can be a dangerous thing - you may negatively impact your health more through worry than from whatever it is you are worried about. And this can even extend to medical testing - sometimes treating a condition (or just knowing you have it & worrying about it) is worse for you than the condition itself.
The author wraps up talking about end of life care. These days medicine has gotten good enough that it can turn positively ghoulish and Frankenstein-like for the old and sick. I've heard the argument made that when our pets are old and in pain we have the decency to have them put down, but we won't do the same for people. And it is worse than that - often we keep people alive long past when nature intended them to be, and add only unhappiness to their lives. He recounts the death of his own parents, and how much more humane they were than someone who ends their days in a hospital bed.
The book tackles these and several other issues, and generally does it in a light, humorous and concise way. He also present his case with facts and data - his case usually being that most of the time you really are just OK, and you are either fine or will heal up good as new with a little patience. And of course he does acknowledge that there are plenty of situations where medical intervention is necessary and beneficial - it's not that medicine isn't good and doesn't work, it is just overused.
A worthy read just to hear a valid point of view that helps you think about how you want to handle your health.
I just finished Less medicine, more health: 7 Assumptions that Drive Too Much Medical Care , and heartily recommend it! The seven assumptions are All Risks can be Lowered, It's always better to Fix the problem, Sooner is Always Better, It never hurts to get more Information, Action is always better than inaction, Newer is Always Better, and It's all about Avoiding Death. Notice those "always" and "never"s? Dr. Welch does recognize that every situation is different and sometimes our new technology is just what is needed. It's assuming that all the situations are the same that sinks us. Completely side stepping the monetary costs of modern medicine, he talks about the medical costs of using these assumptions as if they were universally appropriate. On the Avoiding Death assumption, I'd just point out that given how many people would rather risk diabetes, heart disease, etc. than give up chocolate, the convenience of fast food, alcohol, smoking, and other of life's joys, I think it's pretty clear that quality of life is more important to most people than just adding a few more days. He also mentions (as I have so often pointed out) that sometimes the added "life" is spent uncomfortably, in the hospital. Would you rather have three months at home, or six months in the hospital? Added life should imply an ability to actually live it. I also liked the story from the early days of palliative care where the people who opted for palliation lived three months (on average) longer than those who chose interventions. Live worth living has got to be better than being a guinea pig. Under the "lowering risks" assumption Welch talks about statistics- pointing out that two or three percentage points don't make a huge difference, he suggests that you shouldn't worry until something is two or three times as likely to cause problems. He also suggests waiting several years before trying a new treatment (unless it's your only chance). Wait to see how it plays out in the real world. He tells of a doctor who opted for the all metal hip replacement because he knew that they usually needed replacing every 9 years (how many recipients are told that before it's time to have it replaced?) and wanted longer between major operations, but the new metal ones apparently leaked cobalt into his system, poisoning him, which gave him a lot of psychiatric symptoms, complicating the diagnosis. He also agreed with my uncle Dewey, the doctor, that screening doesn't tend to help much, except making people more scared and get more medical care that doesn't enhance health. (data vs. useful information). Actually, this may make this a life changing book for me. My kids have told me for years that they didn't want to hear all the "fascinating medical trivia" I'd accumulated. I'm now feeling a bit embarrassed that I needed to read it in a book before what they'd told me repeatedly sunk in. Another point he made (about cancers) is that some can be left to watch, you don't always have to do everything, or do it immediately. Often problems resolve themselves. If you enjoy perspectives about medicine from the inside, I heartily recommend this book! (I know I'll be looking for his other titles.)
I am not a doctor nor do I work in the healthcare industry. I'm just an ordinary U.S. citizen who happened to wonder about many of the assumptions Welch addresses in Less Medicine, More Health, which is why I requested a copy.
Welch's writing style was conversational and easy to understand. While there were significant amounts of data and stats discussed as well as medical terminology, at no point did I feel like he was talking over my head. He also succeeded at presenting his case with evidence to support his argument WITHOUT resorting to sensationalism.
I found "Assumption #7: It's All About Avoiding Death" offered me the least new information but the most validation. I couldn't agree more with Welch! If someone could only read one chapter in this book, I would point them to "Assumption #7" because I think it has the most potential as far as life-changing perspectives go. Everyone should focus more on living than doing everything they can to avoid death. Like my sister always says, it's about quality (of life) not quantity.
Welch seemed to genuinely want the reader to ask questions, engage the conversation, and THINK for themselves. His consistency in promoting critical thought combined with his approach to the subject were what earned this book a high rating. It also did not hurt that he donates all royalties from his books to charity, which further supports his case, in my opinion.
Received hardcover from the publisher in exchange for an honest review.
Below are a few quotes I bookmarked:
"You may not consider that a harm, but remember health is not simply a state of physical being--it's also a state of mind. It's more than a little ironic for a health-care system to scare people about their health, particularly when we know that doing so can adversely affect their health (65)."
"Websites will pick it up, and so will Dr. Oz and the rest of the medical self-help and infotainment industry (78)" I found the word "infotainment" quite catchy.
"But that's me. I tend to mark down the benefit of screening because it happens in the future, while the harms are much more immediate. Avoiding death isn't my top priority anyway; I'd rather avoid a lingering cognitive decline in a long-term facility (not that I'm likely to be successful) (82)."
"Just because you have data doesn't mean you have information. Having information doesn't mean you have useful knowledge. And wisdom--well, that's a whole new ball game (95)."
"The fact that healing without intervention is possible can be lost on a highly medicalized society. Some problems will disappear on their own. Others persist, but we adapt to them--and feel better. And still others wax and wane. Ironically, medical care may obscure our capacity to heal: people who have a problem seek care--and get better. These stories of 'success' lead us to conclude that healing was not possible without medical care (133-134)."
"There's no one right approach to anticipatory medicine because there's no one right approach to life and death. It's personal (182)."
I grabbed this book at the ALA Midwinter Meeting because it seemed right up my alley. And I was correct!
About a year ago I read “How We Do Harm,” written by Otis Brawley--the Chief Medical Officer of the American Cancer Society. He was the first perspective I’d read on the potential harms of screening for different types of cancers, and it blew me away. While this book isn’t entirely about screening for cancer, it certainly addresses it, and I feel like everyone should read this important information. Dr. Welch comes up with a really great metaphor for different types of cancers, “the barnyard pen.” Cancers include turtles (slow growing), rabbits (faster but containable), and birds (already gone). Screening only benefits the rabbits, and increases stress and treatment complications in the turtles. Between Welch’s and Brawley’s books, I feel like there’s an answer for people who criticize professional recommendations to reduce the frequency of screenings. Not only that, but he encourages doctors to be upfront about the possibility of abnormal screenings that are meaningless. I still remember how much less stress I had after a pap when the PA who performed it let me know that nearly half of the results in her office have some sort of abnormality. Half! If I got a call back about an abnormality after she told me that, it would have been stressful, sure, but so much less stressful.
Of course, screening is just a small part of the book. Brawley also addresses the concept of having too much information on personal health. In fact, this chapter encouraged me to STOP researching so darn much about some of my health issues, because he’s right; a lot of what I’ve come up with just noise, and not very meaningful, but it sure does manage to stress me out!
This book was short and succinct, which I greatly appreciated. Also, Welch’s sense of humor may very well remind you of your dad, if he were just a little bit funnier. I definitely appreciated this about the book. This is a very easy to read title on this very important topic, with plenty of examples to support his theses.
This book reinforced some basic beliefs of mine - the the more medical care you receive, the worse your health becomes, provided you take care of yourself with proper diet and exercise. In these days of rationing healthcare, self-rationing of medical services is beyond wise. Here are my favorite quotes/summations of the material in the book:
"Medical care can be extremely valuable. But that does not imply it is routinely valuable. Because of the dramatic impact medical care can have on human health, it is tempting to think that seeking it is the most important thing you can do for your health. That exaggerates the importance of medical care: doctors don’t reliably make people feel more resilient (sadly, in the case of those who are well, often the reverse), we can’t make everybody feel good, and we are not the arbitrator of who lives or dies. The reality is more nuanced: medical care is most likely to be important when you are acutely sick or injured – while staying well is a different ball game…While it is not healthy to ignore one’s health, it also is not healthy to obsess about it. Pursuing health requires, ironically, not paying too much attention to it…
Too many people are being made to worry about diseases they don’t have and are at only average risk to get…Too many people are being tested and exposed to the harmful effects of the testing process: the anxiety of false alarms and the vulnerability caused by ambiguous findings, not to mention the complications of diagnostic procedures…Too many people are being treated with treatments they don’t need or can’t benefit from. Treatment interventions can have substantial physical harms, such as medication reactions, surgical complications, even death."
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?
ASSUMPTION #1 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.
ASSUMPTION #2 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.
ASSUMPTION #3 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.”
ASSUMPTION #4 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.
ASSUMPTION #5 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.”
SASUMPTION #6 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.
ASSUMPTION #7 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.
I'm glad I read this at this time! I may be needing to make a decision about cochlear implants in the near future and I think this book will help me with the decision. I'm also reminded how I got hounded and nagged into allowing my wisdom teeth to be removed and I really wish I hadn't done so. I was sick for two months after that surgery and there was no good reason to remove them. Welch says only get them removed if there is pain and there wasn't any pain. GRRRRR. It got me into trouble at work because I was out for 4 days instead of the promised 2 days. I deliberately scheduled the surgery on a Friday so I would have the weekend to recuperate and I barely made it into work the following Friday. I only did so because I was afraid of my boss at that time. Basically, his opinion is that if it ain't broke, don't fix it. I'll remember that from now on. This doctor is at Dartmouth, and clearly knows his medicine. He also has done a lot of reading on studies of what patients really want. These helped him formulate his thesis stated above. I think we all could stand reading this book to get a better mindset before engaging in any medical practice. Or for that matter, alternative medicine as well.
I’m a retired Internist and having some professional bond with the author read the book with great interest. I even had the same experience with a 1990 Ford Explorer which is revealed in his book (the excuse given to me was that it was built just as we entered the Gulf War which might have been distracting to workers). While I don’t agree 100% with the book I would highly recommend this book to medical students and others medical providers in training to be medical providers. It provides a perspective that medical school (at least mine) can gloss over or miss entirely. He presented a balanced perspective in a thoughtful and very witty manner.
The barnyard analogy is about as simple and true as it can possibly get. I wish I could take credit for it. Patients generally feel more testing is better and begin to question physician motives when a discussion of actionable information is considered. I recall p__sing off my mother’s neurologist when a follow up angiogram was recommended to her a year after she suffered a stroke. My mother asked me about having the procedure and we had a general discussion about risks and benefits. I suggested she ask the neurologist whether the results would change therapy since the problem was a relatively rare issue involving the so-called posterior circulation which wasn’t approachable by surgery. The prior angiogram showed 99% occlusion so it was a reasonable question (perhaps there was some good reason to suspect the prior result was reversible such as vasospasm?). Well, my mother asked and the conversation ended promptly after a few disparaging words to the effect, “Who the he__ told you to ask that question?”. I never intervened again.
I loved the section on data, information, useful knowledge and wisdom. The author didn’t go in to electronic medical records (EMR)--um, digitization of the professional relationship--in this particular book. I wish he had but understand the book could have been 1000 pages and missed something I think important. Starting in the late 1990’s I thought the EMR was one of the greatest advances in health care imaginable and later enthusiastically adopted it, at my own expense, in 2000. Despite loss of eye contact (hence part of the personal relationship) I thought that the data collection, marginal efficiencies and some of the safety features (such as drug-drug interaction checking and ways to reduce prescriptive errors) were well worth any dehumanization incurred. While I still think there are limited benefits of the EMR the section on ‘what defines health’ deals with the fundamental reason I entered medicine and ‘documentation, achieving performance goals, or reducing the workload of ancillary personnel (such as billing/scheduling)’ were not part of that decision. I might add that some software programs are worse than others but, trust me, the ones written by the finest software engineers who sideline providers as ‘advisors’ are absolutely the worst. After using two other EMRs (one enthusiastically, the other more of a peasceful coexistence) I happily retired after I decided I would not be taking orders from the third. It would be an EPIC omission not to mention this.
The final issue that I did not think got quite the emphasis is how doctors, either intentionally or not, make the ‘walking wounded’ into professional patients. For those outside of medicine, the walking wounded are patients who are destined to cope with their medical problems--absent an untimely death we all end up in this category. I changed employers in the final year prior to retirement. Part of the transition was a two week orientation to the medical system I had contracted with (yes, they paid me full salary for this!). Maybe the most horrible 2 weeks of my life but beside the point. Toward the end I was required to audit another physician’s practice primarily (I think) to see how he integrated the EMR (the one I learned to hate) into his busy practice. I think there were 17-18 patients on that morning’s schedule which would be a good test of how the EMR could be used efficiently on a busy half day. My first thought, especially given the constraints placed by the computer, was “not possible” which would have been correct given the style of practice I had become accustomed to: See the patient the bare minimum necessary to maintain optimal health, get as much done in those precious few visitis, have time for a personal-professional relationship, address patient concerns (including patient education--very important!) and jointly set goals including anyfollow up. Well, it’s easy to critique others but I can’t remember any patient on that schedule who didn’t get a follow up in less than a 1 month and most were following up in a week or two (a couple in less than 1 week). Shocking to me but I suppose in today’s environment pretty routine. It’s easy to see how the EMR would actually facilitate narrowly focused visits and follow ups like that--just saving the time yammering about various expectations and strategies ‘in case things don’t completely resolve and I see you in a year or two’ can be used to code in all the digits of ICD-10 (such as specifying ‘subsequent encounter’ for getting sucked into a jet engine V97.33xd--look it up yourself). In my training I was warned against being the accomplice in making a reasonably healthy but concerned patient into a ‘cardiac cripple’ by unreasonable testing or worries about transient symptoms that theoretically could be life threatening (such as ‘atypical chest pain’ which is common but rarely heart related). The author implied that we physicians are also in danger of creating ‘professional patients’ by over prescribing and ‘medicalizing’ those who probably are destined for long lives and unlikely to benefit from more rather than less medicine. A lot of this may be motivated by profit but I think it’s more about the gradual transition to a culture that thinks medical science will solve all of our problems and physicians who order more tests or see patients more often must care more. Congratulations to Dr. Welch for at least attempting to strip away that veneer.
Interesting book written by Dr. H. Gilbert Welch, a nationally recognized expert on the effects of medical testing, who is an academic physician at Dartmouth Medical School. His premise is that doctors should only do things that stand up to the rigors of quantitative review., for example he feels that many tests given patients are likely to cause unnecessary procedures to be performed, that research as proven are unnecessary and possibly more harmful. He debunks 7 common assumptions about practices that are very common; 1. That all risks can be lowered, 2. It is always better to fix a problem, 3. Sooner is always better, 4. It never hyrts to get informaation, 5. Action is always better than inaction, 6. Newer is always better, and 7. It is all about avoiding death. I chose this book based on the positive review by Atul Gwande, author of Being Mortal, which I very much appreciated.
Wow! This is a great book for any of us at any age. It is so easy to fall into old assumptions that are not valid. Dr. Welch is a physician on the faculty of Dartmouth Medical School. He counters some ideas that most of us have such as the sooner you are treated, the better. This is not to say that you should ignore physical or emotional problems but you do not always have to rush to get some things "healed." Best of all like a good academic professor, Dr. Welch provides the source of all he asserts. There is a lengthy listing of references articles and books at the end of the book so non-believers can read the research and results for him or her self. A lengthy list of academic reviewers is also included. Anyone concerned about health of any loved ones would do well to read this book. A wonderful addition to that shelf of health books.
The author gives real-life stories of how medicine has gone awry by being driven by the payer driven healthcare system we have in place today. Jonathan Bush points out the eagerness of the dollar over the health of the patient. Robert Morgan in his book about Daniel Boone gives us the realization that we need to return to understanding and accepting the gift of a beautiful death. This book gave some insightful strategies from a physician's point of view as to how our payment system has drifted so far away from the customer that free market is almost nonexistent in today's healthcare environment. This author gives us the individuals/patients, the knowledge or a taste of the knowledge that we need to have. To take back our healthcare from the payer system.
Since I agree with all the ideas in this book, and have for many years, of course I thought it was terrific. I particularly appreciated the correct presentation of statistics (yes, correct statistical methodology is one of my soapboxes). Most doctors are sadly ignorant of statistics and use metrics in ways that can be harmful.
So, getting down off the soapbox, other good things are: the book is written in a pleasant, conversational style, it's an easy, fast read, and if you're fussy there is a complete section of references in the back.
Ready, Aim, Fire! Consider this a direct hit to the idea that an annual physical along with the side tests of pap smear, mammogram and bone density have any usefulness to our health and well-being. Dr. Welch backs up all of his opinions with research, and more importantly interpretation of that research. I now fully understand that certain headlines that report a 50% reduction in certain risks are misleading. If you want to know what is useful medical testing and which is useless, or even harmful, read this book.
Excellent. I highly recommend everyone read this book to better understand the pros and cons of things like cancer screenings. The book is basically about iatrogenics, harm from the healer, which I learned about first from Nassim Taleb in Antifragile. It's important to understand that going to the doctor is likely to cause more problems than it solves in non-emergency situations. This book lays out some of the reasons why this is so in order to make us better health-care consumers.
Welch presents many important topics in a way that is not so intuitive to the average medical consumer, or physician. I recommend his books to friends and family. Key points: always consider the option of doing nothing, there are real risks to screening for disease.
The author of this book is an doctor who is practiced for years as a PCP and now teaches at Dartmouth. One of his areas of expertise is what the data (and these are extensive research studies) about the results of medical screening show and how the screening causes more harm than good.
Three areas where he provides irrefutable proof of the greater harm of medical screening are in screening for breast cancer, prostate cancer, and cervical cancer. One of the interesting facts that he brings out is that these tests are not looking for everything to be okay, but instead they are looking for something to be wrong. He then shows what happens if something looks wrong - may not be - and the harm done from the followup procedures, surgical or otherwise.
Cancer, it turns out, is something we all have somewhere in our body. It is not necessarily a malignant growth or something that is likely to to spread for most people. We live with it, we die with it, but we don't die from it. Dr. Welch has some really interesting studies to back this up.
However, two things drive this medical screening overkill - and most medical professionals don't even realize this, because these "wellness checks" are so ubiquitous in the field - and one of those is money, of course, because insurance pays for procedures, while it is reluctant and sometimes won't pay for consultant medicine that focuses on "eat better, exercise, and lose some weight" kind of health advice. The other thing is Big Pharma. They'd rather you take a pill, which insurance will also pay for, than to fix your lifestyle.
The subtitle of this book is "The Seven Assumptions That Drive Too Much Medical Care." They are (and Dr. Welch disproves each of these):
1. All risks can be lowered (they can't). 2. It's always better to fix the problem (the side effects of prostate cancer surgery to fix the problem are definitely not better than the problem). 3. Sooner is always better (it's not, because rushing into something that may not be a problem long-term creates a long-term, and sometimes, rest-of-your-life problem). 4. It never hurts to get more information (much of the testing that gets done is in pursuit of this, but the majority of it doesn't yield any more understanding, and sometimes information overload can make you and your PCP go off the rails in chasing possible solutions). 5. Action is always better than inaction (it's not, because sometimes if you just leave well enough alone, it will resolve itself). 6. Newer is always better (this is what Big Pharma banks on and this is what newer medical procedures bank on, and while some of the newer medical procedures are better than the older ones, in many cases, newer simply never bears the fruit of better). 7. It's all about avoiding death (this is the engine of modern health care, and it ignores the fact that we're all going to die, whether it's today, tomorrow, next week, next year, or years from now, so you may be delaying the inevitable, but you're sacrificing quality of life for quantity of life, and that is never a good thing).
I would like to encourage everyone to read this book. It is very illuminating. As someone who grew up in a medical family where our general philosophy was if you're dying - or think you are - you might give some thought to seeking medical help. Anything less than that would take care of itself eventually, and you would certainly never go see a doctor if there's not anything wrong.
Modern health care has turned this upside down with "wellness programs" that encourage non-sick people to go to a doctor, go through the wringer to see if they can find anything wrong or that might be wrong, and then go through hell physically and financially to, most likely, find out that there's nothing to be concerned about (and, of course, I'm not referring to the small percentage of people who do have life-threatening illnesses and they choose to seek treatment for it).