In a biting commentary published last Friday in the Huffington Post, Dr. Allen Frances, professor emeritus at Duke University and former chair of its psychiatry department, takes the entire medical community to task for overtesting, overdiagnosing and overtreating.
“Wasteful medical care of milder or nonexistent problems does more harm than good to the individual patient, diverts scarce medical resources away from those who really need them, and is an unsustainable drain on the economy,” he writes.
Frances has spoken out on this topic before — most notably in his field of psychiatry. He has warned repeatedly that the latest version of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-5), which was published last spring, has created “several high-prevalence diagnoses at the fuzzy boundary with normality,” which can lead to unnecessary and even dangerous treatments.
The highly controversial DSM has been used for decades by psychiatrists, psychologists, general practitioners and other health professionals to diagnose and treat mental illnesses.
Frances criticized the process of revising the DSM as “secretive, closed and disorganized.” That charge is especially scathing coming from him, as he headed the committee that reworked the manual.
Beyond psychiatry
In his Huffington Post commentary, Frances takes on all “excesses in medical care,” not just those occurring in psychiatry. The causes he cites for those excesses will be familiar to regular Second Opinion readers:
- Early screening and intervention, which, with very few exceptions, “has turned out to be an oversold, dangerous, and expensive flop.”
- The stretching of the diagnostic definitions of illnesses to include healthy people (disease-mongering).
- The overuse and misuse of computed tomography (CT) and other imaging technology.
- Doctors who “have gotten into the habit of ordering huge batteries of laboratory tests and treating the results while ignoring what is best for this particular patient.”
- Hospitals that “have become frenetic torture chambers” for the dying and that cost “an obscene fortune.”
Frances notes that fixing these medical excesses will not be easy. “Harmful overtesting and overtreating is promoted and protected by the enormous economic and political power of the medical industrial complex,” he writes.
Possible ‘cures’
He then offers a “beginning list” of what needs to be done, which includes the following:
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Tame and shame Big Pharma. Stop the direct to consumer advertising that is allowed only in the US and New Zealand. Prohibit all Pharma contributions to professional associations and consumer groups. Regulate and make transparent all the marketing ploys used to mislead doctors. Force the publication of all clinical research trial data.
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Recognize that all existing medical guidelines that define disease thresholds and make treatment recommendations are suspect. They have been developed by experts in each field who always have an intellectual conflict of interest (and often enough also have a financial conflict of interest) that biases them toward overdiagnosis and overtreatment in their pet area of research interest. New diagnostic standards are as dangerous as new drugs and need the same careful and independent vetting to tame unrealistic diagnostic enthusiasm.
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Medical journals need to be more skeptical of the medical research enterprise and should look toward the harms, not just the potentials, of each new purported advance. They should stop drum beating each new study as if it is another big step toward the cure for cancer — which has proven more elusive than anyone imagined.
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We need to provide more resources to treat the really sick who now often get very inadequate care and at the same time need to protect the really well from getting what is often excessive and harmful care. It is wonderful that medical knowledge and tools have advanced so far, but disheartening that we are so bad at distributing them rationally.
Frances also calls on employers, insurance companies, government payors — and consumers — to become smarter users of health services. Don’t “buy into the idea that more is always better,” he stresses.
And he calls on the media to “expose the real harms, not just the imagined wonders, inherent in medical procedures.”
David vs. Goliath
“This is a David vs. Goliath struggle,” Frances writes. “The forces that benefit from massive overdiagnosis can martial hundreds of billions of dollars a year to promote and protect it. The forces supporting rational medical decision making have access to just a few million dollars a year. The smart money is betting on the big bucks and the status quo.”
“But there is hope,” he adds. “Big Tobacco also seemed impregnable just twenty five years ago but was brought down by hard facts and a tiny band of dedicated reformers. Right sometimes does bring might.”
You can read Frances’ commentary at the Huffington Post website.
