I agree that in the U.S. there is a rapid escalation of over medicalization. Older people seem to expect they will have joint replacements, for example. At my annuals I am given prescriptions for all the tests. I usually skip them. I agree 100% with Barbara Ehrenreich's last book,
Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer. (2018)
I love Ehrenreich—thank you for recommending this book! (And I, too, plan to forgo the tests after a certain age, when anything the tests find would be slow-growing anyway.)
If you will be so kind, let me proselytize against statins for general use to lower cholesterol. Evidence is clear a statin will lower cholesterol; the part about statin-lowered cholesterol number preventing strokes and heart attacks is way less proven. And for anyone having joint and muscle pain issues, don't necessarily listen to physicians who guess neuropathy or arthritis as the cause (with more drugs prescribed). First, stop the statins for a few weeks. Then if the pain decreases or disappears, decide on your own which is preferable for your life: real pain and motion limitation from statins or the off-chance a lower cholesterol number prevents a stroke.
Hilarious...because when I was a hospice nurse we joked about the many patients still on statins while on hospice. Prescription drugs have an almost supernatural power in the minds of some patients. People thought that going off statins meant they would die the next day. That of course was possible, but not because they stopped taking their statin.
Oh believe me, you are preaching to the converted! In so many cases (education is another) we take a particular measure as a proxy for what we really want--health in the case of statins, learning to think critically and write persuasively in the case of Common Core--and we forget that success on the measure is not the same as success with what we actually want to achieve. Statins may improve patients' "numbers," but are the patients actually going to live longer, happier lives because of these drugs? As you point out, this outcome is not as proven.
It is particularly nuts to me that statins can cause such severe muscle and joint pain that patients stop exercising, which we know is healthy!
Thanks for these great columns, Mari! I agree with you about rationing and argue that we ration care in the US all the time without calling it that. Denial of care because insurance doesn't cover it? That's rationing.
I'm thinking about the death rates from colon and breast cancer in the US vs Switzerland and am wondering what the rates look like in the US for insured vs. uninsured and underinsured patients. That is, I wonder if the US has higher death rates than Switzerland because some people don't receive timely care and then when they go to seek care because they are desperate and quite ill, it's too late. In his book HOW WE DO HARM, Otis Brawley, Former Chief Medical Officer on the American Cancer Society, describes a woman coming to the ER with her breast in a plastic bag--it fell off her body due to untreated breast cancer. That was in America. My point is, mortality rates in the US can be hard to draw conclusions from if the patients are not grouped according to who received care and who didn't.
I thought How We Do Harm was such an important book, and, like you, I was horrified by that story about that poor woman. The story was a reminder that parts of the US are almost like the developing world in terms of people's health.
You are right that the population in the two countries getting mammograms is different. My article was getting long, so I didn't have space to include this information, but Switzerland has an opt-out rather than an opt-in system for mammograms. Shortly after moving here, I received a letter in the mail informing me that I had been scheduled for a free mammogram at a center about ten minutes away from my home. If the appointment wasn't convenient, I could change or cancel it, but otherwise they would be expecting me. Because of this system, it is much easier to get mammograms, and my guess is that the majority of women aged 50-69 in Switzerland do get mammograms. By contrast, in theory more women in the US can get mammograms and for a much longer timespan, but in fact whether women get mammograms depends on whether she has insurance and, even if she does, whether she has access to this care. Again, the US has both too much and not enough rationing.
I think a similar thing is going on with colorectal cancer. Colonoscopy is a more sensitive test, so it is better overall, but it is so incredibly unpleasant that probably nowhere near as many people take it as ought to. While the FIT test--especially in Switzerland, where they just mail it to your home--is quick and easy. More people taking a test, even if that test is slightly worse than ideal, will yield better results than fewer people taking a perfect test.
This is all so true. There's so little happy medium in US healthcare. The most important question I leaned to ask my mom's platoon of doctors was, "Will this insanely invasive test potentially lead to a significant beneficial alteration in her current treatment or is it just something you'd like to know?"
Though even in managed systems, you sometimes get this stupidity too. When my MIL was in the hospital getting her hip replaced a few years ago, they managed to both give her (thankfully asymptomatic) covid AND find some tiny indolent tumor in her breast. Why they felt it necessary to do a mammogram on a 78-year-old woman who was there for a completely unrelated surgery, I will never understand. They scared the crap out of her, and we wasted a couple months of the last years of her life trying to get a consensus from multiple doctors over whether she actually needed treatment, which was a bunch of pointless stress for all of us until she, quite rightly, flat out refused anyway. After all that, any organized pain management care or occupational therapy, which would have made a real difference those last 2 years, was nowhere to be found.
I'm sorry that happened to your MIL. We forget that these tests cause real anxiety in patients when they turn up an abnormality that likely won't hurt them. The anxiety is a totally avoidable negative effect. I wish more people felt empowered to speak up with doctors as you did for your mom, and to refuse tests and treatments that don't significantly improve our or our loved ones' health.
I agree wholeheartedly. I am a 78-year old in good health, mostly for two reasons: 1. good genes; 2. staying away from my personal physician (also friend of 50 years and golf partner) who continues to push me for annual tests like PSA and colonoscopies, the results of which are more likely to be harmful than lifesaving. He is not malicious; it's just what he was taught back in medical school those decades ago and what almost every other white coat of his acquaintance does. He also insists on instructing overweight and/or high cholesterol patients to correct those horrors by diet and exercise, completely ignoring his decades of experience that such almost never, never work.
We have a tough time admitting how much our genes influence our health, don't we? It seems so unfair that some people (my dad was one of them) can go their whole lives and live into a healthy old age with almost no need for medical care, while others suffer from so many illnesses. But the solution to this injustice is not to overtreat people like you who really don't need all these tests!
I have been using self-imposed rationing for myself and before my mother passed away, I flat refused multiple tests that would have added nothing to her life and been far too physically devastating to a frail woman in her eighties. The one that made the angriest was a proposed endoscopy! Which was for a vague and not overly bothersome symptom.
For myself, I avoid the medical institutional complex whenever possible and have steadfastly refused a "screening" colonoscopy into my sixties. The push back is huge! But, I'm extremely low risk, have no symptoms and the FIT is fine. I see no need to undertake an invasive procedure with unpleasant risks.
Thanks for your thoughtful analysis, I appreciate your ideas.
Thank you for this terrific comment! I am like you: I will do the screening tests for illnesses where I am at risk (which reminds me: I need to schedule an appointment to have a dermatologist look at my moles!), but after a certain age I will not do the others. I can live with a bit of uncertainty much more than I can live with being on the medical treadmill.
I agree that in the U.S. there is a rapid escalation of over medicalization. Older people seem to expect they will have joint replacements, for example. At my annuals I am given prescriptions for all the tests. I usually skip them. I agree 100% with Barbara Ehrenreich's last book,
Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer. (2018)
I love Ehrenreich—thank you for recommending this book! (And I, too, plan to forgo the tests after a certain age, when anything the tests find would be slow-growing anyway.)
If you will be so kind, let me proselytize against statins for general use to lower cholesterol. Evidence is clear a statin will lower cholesterol; the part about statin-lowered cholesterol number preventing strokes and heart attacks is way less proven. And for anyone having joint and muscle pain issues, don't necessarily listen to physicians who guess neuropathy or arthritis as the cause (with more drugs prescribed). First, stop the statins for a few weeks. Then if the pain decreases or disappears, decide on your own which is preferable for your life: real pain and motion limitation from statins or the off-chance a lower cholesterol number prevents a stroke.
Hilarious...because when I was a hospice nurse we joked about the many patients still on statins while on hospice. Prescription drugs have an almost supernatural power in the minds of some patients. People thought that going off statins meant they would die the next day. That of course was possible, but not because they stopped taking their statin.
Oh believe me, you are preaching to the converted! In so many cases (education is another) we take a particular measure as a proxy for what we really want--health in the case of statins, learning to think critically and write persuasively in the case of Common Core--and we forget that success on the measure is not the same as success with what we actually want to achieve. Statins may improve patients' "numbers," but are the patients actually going to live longer, happier lives because of these drugs? As you point out, this outcome is not as proven.
It is particularly nuts to me that statins can cause such severe muscle and joint pain that patients stop exercising, which we know is healthy!
Thanks for these great columns, Mari! I agree with you about rationing and argue that we ration care in the US all the time without calling it that. Denial of care because insurance doesn't cover it? That's rationing.
I'm thinking about the death rates from colon and breast cancer in the US vs Switzerland and am wondering what the rates look like in the US for insured vs. uninsured and underinsured patients. That is, I wonder if the US has higher death rates than Switzerland because some people don't receive timely care and then when they go to seek care because they are desperate and quite ill, it's too late. In his book HOW WE DO HARM, Otis Brawley, Former Chief Medical Officer on the American Cancer Society, describes a woman coming to the ER with her breast in a plastic bag--it fell off her body due to untreated breast cancer. That was in America. My point is, mortality rates in the US can be hard to draw conclusions from if the patients are not grouped according to who received care and who didn't.
I thought How We Do Harm was such an important book, and, like you, I was horrified by that story about that poor woman. The story was a reminder that parts of the US are almost like the developing world in terms of people's health.
You are right that the population in the two countries getting mammograms is different. My article was getting long, so I didn't have space to include this information, but Switzerland has an opt-out rather than an opt-in system for mammograms. Shortly after moving here, I received a letter in the mail informing me that I had been scheduled for a free mammogram at a center about ten minutes away from my home. If the appointment wasn't convenient, I could change or cancel it, but otherwise they would be expecting me. Because of this system, it is much easier to get mammograms, and my guess is that the majority of women aged 50-69 in Switzerland do get mammograms. By contrast, in theory more women in the US can get mammograms and for a much longer timespan, but in fact whether women get mammograms depends on whether she has insurance and, even if she does, whether she has access to this care. Again, the US has both too much and not enough rationing.
I think a similar thing is going on with colorectal cancer. Colonoscopy is a more sensitive test, so it is better overall, but it is so incredibly unpleasant that probably nowhere near as many people take it as ought to. While the FIT test--especially in Switzerland, where they just mail it to your home--is quick and easy. More people taking a test, even if that test is slightly worse than ideal, will yield better results than fewer people taking a perfect test.
Thanks for the clarification--very helpful. The Swiss way makes a lot of sense. If only...
This is all so true. There's so little happy medium in US healthcare. The most important question I leaned to ask my mom's platoon of doctors was, "Will this insanely invasive test potentially lead to a significant beneficial alteration in her current treatment or is it just something you'd like to know?"
Though even in managed systems, you sometimes get this stupidity too. When my MIL was in the hospital getting her hip replaced a few years ago, they managed to both give her (thankfully asymptomatic) covid AND find some tiny indolent tumor in her breast. Why they felt it necessary to do a mammogram on a 78-year-old woman who was there for a completely unrelated surgery, I will never understand. They scared the crap out of her, and we wasted a couple months of the last years of her life trying to get a consensus from multiple doctors over whether she actually needed treatment, which was a bunch of pointless stress for all of us until she, quite rightly, flat out refused anyway. After all that, any organized pain management care or occupational therapy, which would have made a real difference those last 2 years, was nowhere to be found.
I'm sorry that happened to your MIL. We forget that these tests cause real anxiety in patients when they turn up an abnormality that likely won't hurt them. The anxiety is a totally avoidable negative effect. I wish more people felt empowered to speak up with doctors as you did for your mom, and to refuse tests and treatments that don't significantly improve our or our loved ones' health.
I agree wholeheartedly. I am a 78-year old in good health, mostly for two reasons: 1. good genes; 2. staying away from my personal physician (also friend of 50 years and golf partner) who continues to push me for annual tests like PSA and colonoscopies, the results of which are more likely to be harmful than lifesaving. He is not malicious; it's just what he was taught back in medical school those decades ago and what almost every other white coat of his acquaintance does. He also insists on instructing overweight and/or high cholesterol patients to correct those horrors by diet and exercise, completely ignoring his decades of experience that such almost never, never work.
We have a tough time admitting how much our genes influence our health, don't we? It seems so unfair that some people (my dad was one of them) can go their whole lives and live into a healthy old age with almost no need for medical care, while others suffer from so many illnesses. But the solution to this injustice is not to overtreat people like you who really don't need all these tests!
I have been using self-imposed rationing for myself and before my mother passed away, I flat refused multiple tests that would have added nothing to her life and been far too physically devastating to a frail woman in her eighties. The one that made the angriest was a proposed endoscopy! Which was for a vague and not overly bothersome symptom.
For myself, I avoid the medical institutional complex whenever possible and have steadfastly refused a "screening" colonoscopy into my sixties. The push back is huge! But, I'm extremely low risk, have no symptoms and the FIT is fine. I see no need to undertake an invasive procedure with unpleasant risks.
Thanks for your thoughtful analysis, I appreciate your ideas.
Thank you for this terrific comment! I am like you: I will do the screening tests for illnesses where I am at risk (which reminds me: I need to schedule an appointment to have a dermatologist look at my moles!), but after a certain age I will not do the others. I can live with a bit of uncertainty much more than I can live with being on the medical treadmill.
Yes! Your phrasing is so apt: "the medical treadmill," I'm going to borrow that 😀
Oh, it’s not my phrase—it comes from the NYTimes article I linked to. I agree that it is a very apt term!