Diagnostic thresholds, thinking and health

A recent (May 6) Op-Ed article in the Los Angeles Times entitled, “Diagnosis as disease” brings out some very interesting points about medical diagnosis and thinking of people as diseased. It tells us that “low diagnostic thresholds lead people who feel well to be labeled as unwell.”  “Not surprisingly, some subsequently feel less well.”  “In short, low diagnostic thresholds introduce more ‘dis’-ease into the population.”

The author, H. Gilbert Welch M.D., M.P.H., is a practicing physician and professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and the author of “Overdiagnosed: Making People Sick in the Pursuit of Health”.

He describes how people who have no symptoms of a disease are tested for it, and how there have been changes in the level of abnormality that is considered to be disease. He cites the example where “a fasting blood sugar of 130 was not considered to be diabetes before 1997; now it is”.

Welch says, “the threshold for diagnosis has fallen too low.”  “Physicians are now making diagnoses in individuals who wouldn’t have been considered sick in the past.”

He calls “the person who has been turned into a patient because of a lower threshold” a “marginal patient”. And he points out that marginal patients are “at extremely low risk to experience their ‘disease’ in their lifetime” but still face the “same risk of harm from treatment” and thus “these marginal patients are at extremely high risk not to benefit from treatment.”  He concludes, “in short, low thresholds have a way of leading to treatments that are worse than the disease.”

Here in Michigan we hear the phrases “evidence based” and “best practices” and we have a new MIDashboard with metrics showing progress in the state on different issues.  We have two metrics for health, one for infant mortality and the other for obesity.  So, relevant to us in Michigan, I think, is another observation of his. Welch says that “the movement to measure health-care quality, however well intended, exacerbates the problem.”  “Many performance metrics measure whether diagnostic tests and treatments are being ordered.” And consider again his example of a rule change regarding a fasting blood sugar of 130 and how that might affect the metrics used in our state.

Consider for a moment, too, the situation for any individual in the state who chooses a non-medical spiritual method of care, such as in Christian Science.  Any requirements to medically measure and diagnose every citizen to supply data for metrics on health would tend to impede patient usage of spiritual care because patients who choose this type of care have, by definition, elected to rely on a form of health care that does not include medical diagnosis, prognosis, or treatment.

Welch also discusses factors that have led to lower diagnostic thresholds, such as the pursuit of money, litigation and “our medical culture”.

Now consider this insight offered by Mary Baker Eddy, Founder of Christian Science, in an article entitled “Mental Practice”: “It is admitted that mortals think wickedly and act
wickedly: it is beginning to be seen by thinkers, that mortals think also after a sickly fashion. In common parlance, one person feels sick, another feels wicked. A third person knows that if he would remove this feeling in either case, in the one he must change his patient’s consciousness of dis-ease and suffering to a consciousness of ease and loss of suffering; while in the other he must change the patient’s sense of sinning at ease to a sense of discomfort in sin and peace in goodness.” (Miscellaneous Writings page 219).

She goes on to explain that a state of health is “a state of consciousness made manifest on the body” and thus the need to yield thought, or lift thought, to God, the divine Mind, the divine goodness.

It seems clear that how we measure and think about health contributes to whether we feel at ease or “dis”-ease.

To read Welch’s entire article click here.

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