Are we all sick? Doctors debate "medicalization" of life
■ Human conditions previously thought of as normal now warrant treatment. Medical guidelines are being expanded. And genetic tests are turning more people into patients.
A decade ago, Clifton Meador, MD, predicted that it wouldn't be long before there wasn't a single healthy person left in the United States. Now his forecast might have come to fruition.
"I don't know the last time I saw a really well person," said Dr. Meador, director of the Meharry Vanderbilt Alliance in Nashville. "Everybody's got something."
Ever since making his prediction in a fictional case study, "The Last Well Person," which appeared in the Feb. 10, 1994, New England Journal of Medicine, he has become part of an increasingly vocal group of physicians uneasy about the growing medicalization of life in the United States and the rest of the industrialized world.
Previously typical vagaries -- such as menopause, shyness, shortness of stature or the symptoms of old age -- are now worthy of medical intervention.
Thresholds for cardiovascular disease risk factors such as hypertension and cholesterol have been lowered, leading an increasing number of people to be categorized as "in need of treatment" or to qualify for precursor conditions such as pre-hypertension.
Cancer screening now can detect more and more precancerous lesions. And genetic tests that are starting to become available have the potential to add more people to the ranks of those with disease labels that can be given long before symptoms appear.
Some physicians don't like it.
This kind of medicalization is a threat to health, turning the United States into a nation of overtreated, worried well who are unable to cope with life's normal travails, argues Nortin M. Hadler, MD, professor of medicine, microbiology and immunology at the University of North Carolina. He borrowed, with permission, the title of Dr. Meador's paper for his new book, The Last Well Person: How to Stay Well Despite the Health-Care System.
"People consider themselves ill and take pills every day and are changed," Dr. Hadler said. "They no longer have the sense of invincibility that they had before that is so important."
Still, no one argues that some of these diagnoses and labels can lead to treatment, reduced suffering, improved outcomes and even saved lives. But not always. And that is why some critics question whether the benefits are in all cases worth the price.
Sick and sicker
"We really need some basic research to see whether these designations do have any beneficial outcome other than driving up the cost of health care," said Larry Anderson, MD, a family physician in Wellington, Kan. "At this point, I don't think we're making people ill before their time, but there is a law of diminishing returns."
For instance, there is a populationwide concern that as more people take medication, more people will experience drug side effects. The impact of "sick" labeling on the individual emotional and psychological well-being is also unclear.
Investigation into this question is most extensive for hypertension and cancer. Naysayers cite studies linking a hypertension diagnosis to more work absenteeism, lower earnings, increased depression and a reduced quality of life. They say these negatives outweigh any day-to-day disability caused by the admittedly serious condition.
In the area of cancer, they charge that some screening tests can detect precancerous cells and result in the same stress, anxiety and depression associated with a diagnosis of an advanced tumor, but not all are backed by evidence that such detection improves longevity and quality of life.
Some physicians consider this data to be a call for caution, particularly if it means more and more people are put in the "sick role," defined by sociologists in the 1950s as someone who lacks responsibility for his/her condition, is exempt from day-to-day obligations, wants to get well and is obliged to seek help.
"Worst of all, the diagnosis of disease may lead you to regard yourself as forever flawed," wrote Dr. Richard Smith in the British Medical Journal's April 2002 special issue on medicalization. At the time, he was the BMJ's editor.
Some also worry that increased medicalization could be adversely affecting the role of physicians, particularly by raising expectations of what medicine can do. This apprehension is particularly acute regarding some of the latest-designated, most controversial conditions.
Someone who becomes grumpy in the winter can be diagnosed with seasonal affective disorder. If a patient is fatigued, does he/she have chronic fatigue syndrome? Is a dodgy digestive system always irritable bowel syndrome or gastric reflux?
In this manner, patients are labeled and prescribed. When the diagnosis is spot on, it allows patients to receive needed treatment. But sometimes, especially in more mild cases, many physicians suspect that the symptoms could simply be normal variants of the human condition.
"There are a lot of things we can now treat that we couldn't treat in the past, and medicalization does result in the alleviation of suffering," said Arthur Barsky, MD, psychiatric research director at Brigham and Women's Hospital in Boston. "But the other side of it is that we get lulled into this notion that everything that bothers you is remedial. This robs people of coping skills. It also leads to disappointment and dismay when it turns out that you can't cure things like shyness. There is social anxiety disorder, but for some people, they don't have a disorder. They're just shy."
Potential for empowerment
On the other side of the debate are those who say that the growth of medicalization and the ever-expanding definitions of who is in need of treatment empowers patients. They cite the studies that have found no adverse impact of a hypertension diagnosis, and many physicians say their patients take action rather than taking to their beds. Even those with mild risk factors can work to mitigate them.
Meanwhile, quality of life can improve for those with mild forms of some of the most controversial disease labels such as attention-deficit/hyperactivity disorder or social anxiety disorder.
"My patients feel empowered because they know that there is something they can do to help themselves and they're not just at the whim of the gods," said Kathleen W. Wilson, MD, a New Orleans internist and author of Dispatches from the Frontlines of Medicine, a series of consumer health books.
Authors of guidelines, including the most recent cholesterol directives, say the impact on a patients' mental well-being is factored into their calculations and deliberations.
"I don't think what we've done in this last report has anything to do with calling people sick or not sick," said Scott Grande, MD, lead author of the most recent update of the National Cholesterol Education Guidelines published in the July Circulation. "People can get neurotic about their cholesterol, but the vast majority of people just deal with it."
In the middle are many physicians who say they are under a great deal of pressure to diagnose -- to label -- in order to get third-party payers to pony up for the cost of providing care.
"Doctors are desperately searching for ways to make money so that they can stay in business doing the things that ought to be done but get paid for poorly," said Julie Komarow, MD, a family physician in Covington, Wash.
Overall, there is a great deal of discussion of the trend's impact of labeling on the American psyche. Still, there is no agreement on what it might be. Mental health experts argue that a diagnosis' ability to empower or disempower a person has less to do with the label and more to do with the individual's response to minor and major ills. Some people respond with a sense of futility and anxiety. Others begin to care for themselves. Still others view it as barrier to be overcome.
"Individuals are so variable," Dr. Barsky said. "You see people who can cope amazingly well with really pretty awful diseases, and then you see people who are really terribly distressed at stuff that's just bothersome."
Experts do, however, have theories about how an adverse reaction can be mitigated.
"It's not the information that's the problem. It's the delivery," said Jeffrey Samet, MD, MPH, professor of medicine and public health at Boston University School of Medicine. "We know that controlling your blood pressure with medications, you'll avoid heart attack and stroke. How can we not share with people? We don't have to frame it in ways where you're powerless. On the contrary, we should frame it in a way that this empowers people to take action."
And while medicalization is a hot debate, no one is able to draw precisely the line between just enough and too much.
"This is something that society has to consider," said John Weiler, MD, professor emeritus of internal medicine with the University of Iowa. "If you can find things that will impact on your life and you'll live to be 150 years old and you'll be very healthy, I'm all for that. But when what you're talking about has no impact on your life span and may not have a lot of impact on your well-being, it's hard to make an argument that it's worth the money."
Ultimately, the real transformation could be occurring in terms of what it means to be a patient -- which is very different now than it was in the 1950s.
"I don't think that Americans are feeling that they're sick all the time," said Patrick Tranmer, MD, department head of family medicine at the University of Illinois, Chicago. "I think that they're becoming more aware of the spectrum of health and what they can do earlier to maintain their health."