Are we all sick? Doctors debate medicalization of life.

[Guest guest]

SSRI-Research@

Wed, 29 Sep 2004 20:04:29 -0400

Are we all sick? Doctors debate " medicalization " of life.

 

 

 

-- the answer? We are NOW....

 

 

http://www.ama-assn.org/amednews/2004/09/20/hlsa0920.htm

 

HEALTH & SCIENCE

 

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.

 

By Victoria Stagg Elliott, AMNews staff. Sept. 20, 2004.

 

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. "

 

ADDITIONAL INFORMATION: Who says it's a disease?

 

Two years ago, the British Medical Journal asked readers to pick the

top human processes or problems increasingly being defined as medical

conditions. Among those that made the list:

 

Aging

Bags under eyes

Baldness

Big ears

Boredom

Cellulite

Childbirth

Freckles

Gray or white hair

Hangover

Jet lag

Loneliness

Pregnancy

Road rage

Ugliness

Unhappiness

 

Source: BMJ, Feb. 15, 2002