“Medicalizing” Life

How much medical care do we want in our lives? H. Gilbert Welch poses this question in his excellent op-ed piece for the LA Times entitled, “The Medicalization of Life”  and tells us that the answer will be vitally important for reining in the spiraling cost of health care.

We’ve written a lot about cutting out the waste and over-treatment that is inherently part of our profit-driven health care system. The culprits are clear: Too many scans, too many diagnostic tests, too much surgery and too many prescriptions for expensive new drugs. But despite increasing evidence of where cuts can be made, we’ve always assumed that Americans help drive health care spending with their constant demand for newer and more advanced treatments and technologies.

Welch, professor of medicine at the Dartmouth Institute of Health Policy & Clinical Practice, is asking us to take a far more critical view of these advances and the relative risks and benefits they have to offer. Author of the book, “Should I Be Tested for Cancer,” he is part of a growing movement that encourages “just saying No” to routine tests, treatments and surgeries that have little benefit and may even cause harm—and saying “yes” to watchful waiting, lifestyle changes and in the end of life, palliative care.

In his op-ed, Welch highlights two points in life when medical care can be the most intensive and intrusive: birth and death. Of birth, he says;

“Two of the most common tests preformed on pregnant American women are obstetrical ultrasound and electronic fetal monitoring. After reviewing experimental studies involving more than 27,000 women, the Cochrane Review — an independent, international collaboration that summarizes evidence for medical procedures — found that routine late-pregnancy ultrasound ‘does not confer benefit on mother or baby.’

“But it does do a good job of scaring expectant parents.” The scans pick up minor anatomical abnormalities that can, in rare instances, signal a serious genetic problem like Down syndrome. This leads to anxiety for parents and further testing and interventions for the fetus—even though, says Welch, “minor anatomical abnormalities are about 30 times more common than the genetic disorders they have been associated with.”

Routine fetal monitoring also fits into Welch’s view of the over-medicalization of birth. In their latest clinical guidelines, the American College of Obstetricians and Gynecologists (ACOG) notes that routine use of electronic fetal monitoring grew from 45% in 1980 to 85% in 2002. Despite that increase, fetal mortality and the incidence of cerebral palsy have not decreased. In fact, the false positive rate in predicting cerebral palsy with fetal monitoring is “greater than 99%” according to ACOG—meaning that only one or two out of 1,000 fetuses with “nonreassuring” monitor readings will actually develop cerebral palsy. Most of them will end up delivered through C-sections or with forceps. And although fetal monitoring can sometimes predict seizures, Welch notes that 100 extra women will undergo C-sections to avoid just one seizure.

“The increase in fetal monitoring is part of the explanation for why the beginning of life now involves major surgery one-third of the time,” he says.

The medicalization of the end of life has been well-documented. Spending on the last year of life makes up one-third of all Medicare expenses and dying patients routinely see 10 doctors or more during their last six months of life. They undergo countless tests, surgeries and other treatments—often to end up dying in the ICU instead of at home in peace.

To answer Welch’s question about how much medical care we want in our lives, it’s first important to lay out the risks and benefits. Evidence is accumulating that some of the tests and treatments we once considered beneficial are now questionable in many cases: MRIs for back pain, prostate cancer screening, yearly mammograms under 50, cholesterol-lowering drugs and diabetes treatments—just to name a few. In order to make our choices we must have better evidence-based information and unbiased guidance from practitioners.

Welch writes;

“Medicalization is the process of turning more people into patients. It encourages more of us to be anxious about our health and undermines our confidence in our own bodies. It leads people to have too much treatment — and some of them are harmed by it.

And it's big part of the reason why medical care costs so much.”

10 thoughts on ““Medicalizing” Life

  1. As I understand it, only about 10% of our health status is attributable to the healthcare we receive and have access to. Roughly 40% is due to personal behavior like smoking, drinking, obesity, etc., 30% relates to genetic factors, 20% to environmental factors and socio-economic status but only 10% to what we get from the healthcare system. I wonder if there is any research that attempts to quantify what life expectancy in the developed world might be if we held the healthcare system constant but assumed that nobody smoked, nobody was obese, nobody died in accidents, was murdered or committed suicide and everyone had access to clean housing, safe neighborhoods and healthy food. If life expectancy turned out to be only modestly higher in that near perfect world, it suggests that the benefits of healthcare are significantly overstated at least as it relates to life expectancy.

  2. This is why allowing women with low-risk pregnancies to deliver in a birth center staffed by midwives is such a good idea. Not only does it save money, but it allows women to deliver in less stressful environments and exercise more control over the delivery process.

  3. Calling a normal variant of life an illness clearly is one of the reasons for increased costs, because medical ailments then demand medical treatment. Thus a person who is constitutionally a bit moody ends up on SSRIs. And so on . . .

  4. Barry, a broader definition of a healthcare system -adopted in other countries – includes primary care, public health and health promotion, and so covers much more the determinants of health. The American model is too focused on (very expensive) acute care.

  5. Want to cut costs? Eliminate the people!!!
    From M. Somerville’s column in the 3/12 edition of *The Globe and Mail*:
    “… what are the attitudes of pro-euthanasia advocates regarding whether its use needs to be justified, were it to be legalized? And, if justifications are required, what are they?

    ***And what about avoiding health-care costs as a justification? Although this question has largely been dodged – one could say “religiously” – by pro-euthanasia advocates, [involuntary] euthanasia could be used as a cost-saving measure, and is likely to be if legalized.***
    Half of the lifetime health-care costs of the average person are incurred in the last six months of the person’s life. Euthanasia would be a way to implement a “reasonably well or dead” approach – sometimes referred to as “squaring the curve” of health decline at the end of life, so the person drops precipitously from being reasonably well to dead – which would avoid those costs.
    The medical authority of the U.S. state of Oregon – where physician-assisted suicide is legal – seems to have adopted this approach. Shortly before he died this month, Montreal journalist Hugh Anderson wrote in The Gazette that Oregon “has acknowledged that when it turns down an application to cover the cost of an expensive new drug, it sends out simultaneously a reminder that the state’s assisted suicide program is available at an affordable cost.” As Mr. Anderson noted, “What a great way to put a crimp in medical costs. Have the patients kill themselves when the cost of keeping us alive gets too high.”
    The Netherlands’ 30-year experience with euthanasia shows clearly the rapid expansion, in practice, of what is seen as an acceptable justification for euthanasia.
    Initially, euthanasia was limited to terminally ill, competent adults, with unrelievable pain and suffering, who repeatedly asked for euthanasia and gave their informed consent to it. Now, none of those requirements necessarily applies, in some cases not even in theory and, in others, not in practice.
    For instance, parents of severely disabled babies can request euthanasia for them, 12- to 16-year-olds can obtain euthanasia with parental consent and those over 16 can give their own consent. More than 500 deaths a year, where the adult was incompetent or consent not obtained, result from euthanasia. And late middle-aged men (a group at increased risk for suicide) may be using it as a substitute for suicide.
    Indeed, one of the people responsible for shepherding through the legislation legalizing euthanasia in the Netherlands recently admitted publicly that doing so had been a serious mistake, because, he said, once legalized, euthanasia cannot be controlled. In other words, justifications for it expand greatly, even to the extent that simply a personal preference “to be dead” will suffice.
    Legalizing euthanasia causes death and dying to lose the moral context within which they must be viewed. Maintaining that moral context is crucial in light of an aging population and scarce and increasingly expensive health-care resources, which will present us with increasingly difficult ethical decisions.”
    That *is* the Grim Reaper following Nancy Pelosi, and he is sharpening his scythe as we speak.

  6. We allocate huge sums of money to war activities that cause horrific losses of life, mental & physical disabilities. And yet, the interests of the powerful people that profit from such activities, more sensible options are continually bypassed. The same is true with the corporations profiting from medical device & pharmaceutical sales. Illness=$$ for them. We are drenched in misinformation. Real public healthcare is at stake. (At present they are working hard to control our access to supplements –beware)

  7. I think elders in America need more to do! Half of them don’t have anything better to talk about then their last or their upcoming medical procedure/appointment.
    Is it free entertainment for them? I have to wonder.

  8. GingerG, have a little respect! I doubt most seniors truly enjoy being scared into being poked and prodded in their last years. While I strongly believe in dying a natural death at home with my family, who knows what I will be scared into when I’m 75 rather than 25!
    Still, Dr. Welch (and Naomi Freundlich) has a very valid point about over-screening and the consequential over-diagnoses. I don’t know what he has to say about PKU and metabolic screening tests for newborns, but this is the only procedure I had performed on my newborn baby girl, 3 years ago. Her results came back abnormal, and though I knew there was a very high false-positive rate, I couldn’t help but worry about my beautiful little person. The real moment of fear came when I realized that a metabolic disorder doesn’t just mean that I would have to discontinue nursing (a preventative health measure for both mom and baby that I’m very passionate about), but that the concern now became whether or not my bright-eyed little girl would become mentally retarded or even die! After retesting, my clinic scheduled an appointment with a “specialist” to read the results. My daughter’s pediatrician HAD THE RESULTS, but made me wait an additional 3 weeks for a specialist to read them off the paper to me!! If she actually had this metabolic disorder, how much time would have been wasted simply waiting so that a specialist could read a few sentences?? In the end, she had some abnormal levels, but because she had no symptoms and not all of her levels were abnormal, the specialist considered her to be healthy. Meanwhile I wasted the first 2 months of her new life worrying if I was going to lose her (and yes, I did continue to breastfeed- she weaned shortly before 3 years). The point of this anecdote is, how many families had to suffer like ours did in order to save one child who would probably exhibit symptoms anyway? I cannot be sure, but I would guess hundreds, maybe even thousands (considering the high rate of false positives vs. the rarity of these diseases).
    Meanwhile, much of our “preventative care,” as Dr. Welch pointed out (in this or another article), equates an increase in testing and medication, not health-promoting preventative steps such as increasing exercise or changing other lifestyle factors. How does it really promote health to increase our consumption of prescription meds (when it’s likely that the majority of us would be better off without them), and fail to place the emphasis on lifestyle factors?
    What kinds of health changes could we see in this country if we invested a large portion of our “health reform” $$ into free community gyms, subsidization of healthy produce to lower the costs to consumers (not corn, wheat, and soy as we currently do), and encourage general well-being through community programs, like paying private employers to offer paid time off for lower-income workers to go to the gym. If we are going to socialize health care, let’s at least go further into debt with a program that is going to be effective!