This essays accurately prescribes the diagnose-and-prescribe mentality that persists in much of Western medicine. What also happens frequently is stereotyping. For example, if you are a senior, you automatically are a candidate for statins or blood pressure drugs just because of age, never mind that the tests are normal. Sadly, Duke Unversity’s so-called primary care units adhere to this policy, which must reap incredible financial results from unknowing patients.
1
The psychiatrist Szasz wrote an entire book on this a couple decades ago.
It’s also more lucrative for the medical systems to keep shuffling patients around to innumerable specialists, doing unnecessary testing knowing the likelihood of them being normal is high (protest probability) and that the symptoms are an expected response to a socioeconomic situation which is intolerable to most.
2
Fibromyalgia is a “diagnosis” in name only. The frail “evidence” may evdicenc that there are real biological markers and this is a “real” disease are politicized and utterly unconvincing, albeit widely bruited on the internet. It is a benign capitulation to emotionally frail/disturbed patients to make them fell better as this article suggests. This is charitable and perhaps appropriate, but it can also mislead the general public. These people need psychiatric therapy more than anything.
1
If one sees a "provider', he cannot go home without a pill or a diagnosis or further testing,- even it may be nothing. This -something must be diagnosed is to earn money. U.S. spends over 17% of its GDP in such misgivings. How stupid we are- DOH or doh!
5
This is a very thoughtful and timely essay. The author is spot on with many of his assertions.
In regards to fibromyalgia (FM).I would like to share some thoughts. I practiced rheumatology for almost thirty years and I saw many patients with this syndrome. Folks that I labeled with this diagnosis usually had a constellation of symptoms, including; widespread muscle pain, headaches, TMJ, irritable bowel, insomnia and depression. These people were utterly miserable. They were experiencing psycho-soma meltdown. Over time I came to realize that there probably multiple factors that led to the development of FM. These include stress, poor sleep, depression, poor condition, genetic factors etc. One factor that became evident over time, was a previous history of severe physical and/or sexual abuse, including rape.
I began to think that FM was a manifestation of PTSD.
The treatment of FM is problematic. There is no “cure.” If narcotics are used the person will usually become addicted to them. A multi-faceted approach can be of benefit, including antidepressants, PT/OT, counseling and exercise.
7
What difference does a diagnosis make? Physicians are, for the most part, overpaid sales persons for the pharmaceutical industry and diagnostic equipment manufacturers. You can be sure that if you visit a physician, you'll end up with a diagnosis of something or other, and a prescription for expensive (and usually useless and toxic) pharmaceuticals and/or an expensive (and useless) diagnostic procedure. It all starts with those $200-$300K medical educations they get. It's all about money.
6
With a potentially fatal condition, the correct diagnosis can, literally, mean the difference between life or death.
9
I am not sure lifestyle changes come without side effects. Some are onerous and may require difficult adjustments and reduce quality of life. Classifying them as cost-free sounds about as thoughtful as the later statement about drones.
5
One notable example of this trend is the recent explosion of television ads for "free testosterone boosters," which claim to relieve the normal decline in muscle mass and libido that is part of normal ageing. Reading the label shows that these nostrums are typically composed of plant extracts plus vitamins and minerals. which are (according to my friend, a professor of endocrinology) completely worthless, albeit mostly harmless. Thus is normal ageing converted into a disease, with a pill to fix it. Losing weight, getting more exercise, getting your blood pressure and cholesterol checked, etc. etc. is more likely to do some good, but that's a lot more work than taking a pill.
5
Marvelous, well written and right on target!
Henry Bernstein
4
I am quite disappointed to see so much bias against medication for psychiatric disorders. The brain is an organ. While I love much about nature, the misery of those suffering from health issues is indeed natural and yet not cause for celebration. I would hate to see someone denied the opportunity for relief because others rather condescendingly believe their pain and misery to be part of “normal living.”
25
I was extremely relieved to finally be diagnosed with ADD at age 50. It explained so much. Whole I grieve for my younger self who did so poorly in school (I now have an M.A.), and was constantly told to work harder, pay attention, get organized, I can now forgive myself. I take meds, which help, but also have researched strategies for managing my ADD. My diagnosis also also helps my spouse to understand my behavior, which I admit can be annoying and frustrating.
11
@Been there
Ditto - diagnosed in my 50s. In my case, stimulant meds have not worked. However, having a diagnosis for what seems like chronic self-sabotage and its consequences has helped.
I resisted the diagnosis for a couple of years...and I groan when I can't get something done in a timely manner...but I'm learning to work with it.
5
Due to the moral panic over painkillers, it's looking like underdiagnosing due to doctor fear is more of a problem than overdiagnosing (unless, of course, it's an SSRI which doctors appear to wish to mail to everyone to save themselves some time). Patients shouldn't wait for six weeks for an SSRI to have some "effect" on crippling anxiety and/or panic (along with the often debilitating side effects of such drugs) when a short course of other drugs can completely and efficiently control the situation when a careful treatment and taper-off plan is in place.
7
Dr. Khullar hits the nail - affirming that only the extremes of certain conditions should be pegged with a diagnosis and proposed active treatment. In my family medicine practice, I like to joke with my office-mates, saying, “The human body is capable of many odd and uncomfortable sensations - most of which are entirely meaningless.” It is not a line I could easily use with patients seeking answers. But the concept can lead to a discussion of the importance of self care to manage many of our ills.
12
I'll tell you one thing, Dr Khuliar--if my doctors can't diagnose it, my insurance company won't pay for it. And I have really good insurance.
I expect that's at much at the root of diagnoses as some of the other reasons you raise.
35
With the current chaos in the medical system that was instigated by managed care, it is no wonder that patients are mis-diagnosed or not diagnosed correctly, and/or given the wrong or less effective treatments. The average internist is allowed to see a new patient for 15 minutes with follow-up visits limited to 15.5 minutes. There is not time to breathe much less time to think creatively or in depth about a person’s sometimes mysterious symptoms.
Worse, at least for the first consultation,
women patients are assumed to be depressed and are given anti-depressants often inappropriately. Women patients in general are blown off. My hypothyroid dx took 3 years to be named—b/c my then internist felt I was tired, depressed and overworking. Possibly true, but those sx can be caused by hypothyroidism.
I have come to agree w/ the position taken by Frank Aptos, MD, Below. I’m not wild about gov as single payor, but they might do better than the mess as it exists.
The other part of this is that all may not be over-medicalization but rather accurate naming of newer disease entities now that ways to trat them are available.
Ex: Most psychotic illness were lumped under “schizophrenia” at the beginning of the 20th cenftury. Better diagnostics and meds to treat illnesses emerged, and manic-depressive illness was distinguished from schizophrenia. Lithium became available to treat it in 1970. The first anti-depressant became available in 1960, w/ the first antipsychotic in 1950.
6
Dr. Khullar,
These are not new problems. Doctors want to help their patients any way they can. They just can’t see the future.
My father, later a well-known surgeon, was treated with radiation for acne back in the 1920’s. He later developed basal cell carcinomas ,probably related to it, in his 70’s.
I gained a little weight at 14 and was put on thyroid extract until the doctors at my medical school thought it was pointless and took me off it. No ill effects so far.
In my life as first a pediatrician I was pressured to put children on stimulants (this was in the 70’s) but refused because no one knew the long term effects. Later, my own son’s school suggested stimulants might help him, but for the same reason I demurred. (He graduated with honors from a prestigious school and went on to get a master’s in Arabic.
Later as a psychiatrist I worried con
I myself suffered a terrible but rare side effect from a widely prescribed medication for osteoporosis and am still handicapped, but better. Not enough to return to practice as a physician
8
I've been a primary care physician for 40 years now.
A modest proposal:
Single payor medicine.
Do away with fee for service and pay doctors a salary.
Turn big pharma into a pubic utility.
Do away for direct to patient advertising.
80
All these new diseases since the 80’s. Wasn’t that about the time we banned smoking, and second- hand smoke from....everywhere? Ok, save all the responses...just jerking a chain, so to speak. But I might add that the only time I ever had heartburn was during the three years I didn’t smoke.
2
Hmmm....
"Often overlooked, however, are how the psychologies of doctors and patients contribute,"
Yes indeed. And then you juxtapose that aspect against an industry designed and driven to maximize its profits to its shareholders by intensifying the uptake in the products they supply to their customers and you have a tailor made medical and pharmaceutical industry bonfire don't you? With everyone associated in those industries leaning into it hoping to make their profit "marshmellows" as toasty and tasty (for themselves) as they can.
No wonder there's been a literal explosion in underlying diagnosis' (of ailments) of all types. An explosion well beyond true justification. It's Capitalism 101, isn't it? That bonfire must be fed.
John~
American Net'Zen
2
As Dr. Khullar has noted the "medicalization" of American life, I have noticed the pluralization of American English. His interesting column is an example. Therein "diagnoses" replaces "diagnosis", "treatments" replaces "treatment", "medications" replaces "medication", "conditions" replaces "condition", "costs" replaces "cost", and "psychologies" replaces "psychology". This phenomenon possibly started with merchandising, as in "wines and liquors", "artisanal breads", and the like, the better to sound posh. In any case, unnecessary complication seems to be a common denominator of many aspects of modern life.
9
Wow. I mean wow. Mixing two very different issues can be dangerous.
Is this about whether physicians should not over prescribe or is it about medicalization? Back pain comes and goes. Blood pressure goes up and down. Tumors sometimes metastasize. How dare this physician lump together various (and clearly “disease” states) as somehow less worthy of a diagnosis based on seemingly subjective and arbitrary (and prejudicial) bases.
Should physicians seek to not overuse meds and to discontinue them more often: yes. This is as true for antibiotics as it is for insomnia and depression. (Both well describes in the time of Hippocrates). The rest of this essay is simply ridiculous and I don’t have the space here to go through the various elements one by one.
7
I would look to the pharmaceutical industry. They are peddling so many drugs, encouraging all to take their drugs, that people are increasingly dependent. The number of ads by drug companies must outnumber all others by a huge margin. And even with the endless list of side effects, they are luring people into their webs. This is shameful and ever growing.
9
You write: "... there was a 40-fold increase in childhood bipolar disorder diagnoses between 1994 and 2003 ..." Let's take a ride out to the cemetery, and I'll explain why this may not have been a bad thing ... why, in fact, it may have been too little, too late.
12
You lost me at PTSD. Hardly a new “medicalization” of normal life. In WWI there was shell shock, in WWII battle fatigue, and since Vietnam, PTSD. I’m sure the history goes back to the Pelopenesian War and beyond. That you chose Veterans Day for this thoughtless slur is doubly offensive.
23
A few years ago I visited the doctor and discussed some stomach symptoms I was having. They were unpleasant and were occasionally an inconvenience. After I tested negative for the most likely culprits we decided that I had IBS. There were a few medicines out there to treat it but I tried limiting my lactose intake as that is a common cause of IBS. It helped a bit but what helped even more and took me a few years to figure out was that my while not bad was not the best. I upped my intake of fruits and veggies and reduced my red meat and sugar consumption. After that all of my stomach problems disappeared.
The moral of the story is that lifestyle is as important if not more important than medicine in a lot of these vague systemic disorders that were created over the past few years.
10
Same here. Ridding my diet of red meats has led to a substantial decrease in my GERD and other digestive issues.
4
Stores are NOT being replaced by Amazon drones. Drone delivery is a fantasy that has never been implemented, for good reason: Big enough drones are dangerous, and no drone can ring a doorbell, put a package in a mail slot or leave it right by your front door. A drone five feet off the ground is lethal.
On-line merchants, with delivery by truck, have taken business from stores. Most stores are competing by putting themselves on-line.
Nonsense discredits anything worthwhile in an op-ed.
8
One item that has increased the tendency to overdiagnose is the electronic medical record. When I get a print out after a visit, you would think I was on my last legs with all the diagnosis codes that are given. Some of this relates to reimbursement under Medicareand other insurance. Some of it just the fact that now instead of a handwritten notes, the doctor had to pick a diagnosis code. Some of this is good, in that medicine becomes more data driven(we can track efficavy but bad because everybody now has a list of diagnoses attached to their health.
12
I see this article as just another to get out of helping patients out, usually due to cost. I used to have to go to military medicine. Doctors are fine, nurses, etc, but there are limits to what they will do or can due. It's not great to hear that the drug that may help you is not on the list, therefore you won't get it. We were overseas, couldn't buy it if we wanted to. Continuity of care? Ha! Finding new diseases will help those that have the disease, or maybe, if they can't be helped now, in the future. I was diagnosed with fibromyaglia after a long time of having disparate symptoms. I was a working mom with 3 young kids and we were very active. Referred to a specialist, he started me on two drugs that didn't work and then we went to lyrica, which for me was a miracle drug. If I was still overseas, I couldn't get it, but that saves money for the gov't. A few years later, began having other strange symptoms, many physical, which is a god send, since many physicians seem to think a patient that is sick without physical symptoms has a 'psychological' problem. I got sicker and sicker, had 4 doctors trying to figure it out. Luckily I live in an area with a great medical center and all my doctors not only talk to me, but each other. Finally, a diagnosis, a rare autoimmune disease. A long process of trying to get better, lots of medicine, but it's not helped by natural food or more fiber. Instead of looking for ways to get out of helping people, maybe try the opposite.
4
@Moira Rogow
Sorry, but patients who are “sick” without physical symptoms DO have a “psychological” problem...by definition and fact. Did your lab results reflect that your were “sick” or getting “sicker and sicker” ?
@John Whitc
I would assume "rare autoimmune disease" according to you "by definition and fact" reflects multiple documented lab abnormalities.
Also, you are ignoring that many illnesses or syndromes have complex mixes of bio-psycho-social causes. All three are "real" and need to be addressed by medical, therapeutic and lifestyle treatments. This is often timeconsuming and expensive, and not all patients have access to these resources.
I would think being given a diagnosis for a condition that may or may not be an illness might jeopardize insurance should preexisting conditions again become a reason for insurers to decline coverage.
8
Years ago cigarettes were the biggest advertisers on TV. Its now medications by Big Pharma. Many of these meds seem to be meds seeking a disease. Additionally the advertised side effect of the meds seem to be more serious than the disease the meds claim to ease or cure. We have become an over medicated society
25
@impegleg A good rule of thumb is: If it is advertised on television that means they can't persuade doctors to prescribe it, so it's necessary to bring in patient pressure through "asking your doctor." When the list of complications is longer than the sales message, caveat emptor! Long-shot, Hail Mary medicines of questionable value for the average person.
20
Add to that list, chronic low back pain. As a provider in the field for over 20 years, the most common question I get is 'what causes the pain?'. I explained that after you rule out serious diagnosis or 'red flag' conditions, i.e. cancer, infection, etc, one cannot find a specific source of pain. Patients are often frustrated or confused when I cannot give a 'specific' answer. Modern medicine with expensive fancy tests like MRI gives the 'illusion' of be-all end-all certainty. Attempts to pinpoint the 'specific' pain leads to expensive, unproven, and unnecessary procedures and surgeries which , of course, many doctors, surgeons and hospitals are more than willing to do.
12
@Twilight Zone - Dare I suggest many of your patients are overweight/obese, have sedentary existences and frequent poor posture and hence have weak muscles and muscle imbalances causing back pain?
9
@David or MAYBE "You can't have a disc problem....you're too young...you're not overweight...." Turns out I had 3 ruptured discs, 1 impinging on a nerve causing such pain that, after 2 1/2 years of trying to get relief, I finally got a diagnosis, I was about ready to jump off of the roof. Thank goodness for my rock-star surgeon, who has given me back my life. Every patient is different.
4
My friend brought her 2nd grader to the doctor for insomnia. Doc prescribed Klonopin, an anti-epilepsy sedative with very serious side effects. For a seven-year-old. Who was on a stimulant for ADD and played on her iPad until bedtime.
Fortunately the girl’s parents have some critical thinking skills and decided to try less iPad time and a weighted blanket first. Problem solved. But why are doctors so quick to throw meds at little kids as a first choice?
41
Dr. Khullar , I fully agree with your analysis.
The biggest problem with American healthcare is that it is not accessible or affordable to everyone and it is based on “ profit “.
I have the fortune to compare American and European healthcare systems and to see how in America every symptom is quickly labeled with a disease and therefore chained to some sort of expensive prescription drug .
Europeans not having to worry about medical costs or coverage have a different approach to the process of healing, concentrating more on the person as a whole, instead of just the symptoms.
It is so troublesome to me , when back in the USA , to see on television all those incessant Big Pharma advertising’s , with deceitful innuendos , to convince American patients to ask their doctors for every kind of expensive remedies for various illnesses, mimicking symptoms on the screen, to the point of inducing tv viewers to assume those symptoms for themselves.
In many situations certain symptoms are a manifestation of an interior disarray, that our psyche with the help of our immune system can heal without any chemical intervention.
We have to recognize that our body is built to withstand many negative situations.
There are many illnesses that require immediate and continuous pharmacological treatment , the important issue is to find a concerned doctor able to follow and guide us through the meandering paths of current medical available treatments, not necessarily pharmacological.
22
Perfect example. Acid reflux meds. Everyone was routinely prescribed as they were thought pretty benign. Turns out changing the effect of those acid pumps had significant effect on many people's biochemical stasis.
How many people were counseled on foods, sleep time, posture, and the several lifestyle tips that can help? Easier to hand over a medication in a two minute consult.
There is a reason hospital, insurance and pharmaceutical businesses are some of the fastest growing.
14
@maryann
Yes, acid reflex meds may be over prescribed but in my case were necessary. I was exhibiting symptoms of asthma which was caused by aspirating acid into my lungs. This was determined after extensive testing. I do have concerns about the side effects but believe the drug is necessary to keep my lungs from being damaged.
Diagnosis is complicated because of the epigenetics and the quality of the food supply. I was sent down the path of meds when the US decided to add folic acid to the food supply, without notification to those who don't have the genetics to process it. Dropping all enriched grain products has cured the anemia it induced. Of course, the medical solution was surgery and iron pills, blindly given as the insurance company didn't want to do genetic testing or more bloodwork to actually find the root cause of my fatigue and paleness.
Lets also talk about Vitamin D deficiency...that affects 1/3 of the population and where is the medical establishment on this?? Advice to allow us to survive but not thrive is useless. Get the studies done.
4
I agree with Dr. Khullar about overmedicalization. However, ca. 1985 a name was given to a little-known rare blood cancer: T Cell Large Granular Lymphocyte Leukemia. A long-used blue stain highlighted those lymphocytes with 'azurophilic granules' under a microscope and determined a diagnosis. As technology gave lab scientists better diagnostic tools, flow cytometry is now a definitive method for T-LGLL diagnosis.
This is not a case of overmedicalization but a condition in which something more than a physician's intuition and desire to diagnose are brought into use. The author refers to behavioral conditions for which MRIs, ultrasound, blood workups, etc., are not useful except to rule out other suspected conditions. Medical science is still struggling to comprehend the array of human behaviors.
Big Pharma has provided a few costly drugs for a large variety of blood cancers, especially for so-called orphan diseases like T-LGLL which is diagnosed in about 1,000 patients annually in the US. How many blood cancers go undiagnosed? “Watch and wait” in the indolent phase is preferred until the disease worsens. No one with depression, overwhelming fatigue, or asthma would accept a “watch and wait” recommendation.
Those patients with T-LGLL in the indolent phase live in a shadow world expecting the worse. It's not a happy diagnosis. Drugs may produce remission. Longevity is an estimate. In some blood cancers, being closer to overmedicalization would be a gift to patients.
3
Doctors seem to be trained to push "preventive medications" rather than looking at the patient as an individual and discussing the patient's life style and quality of life. This seems particularly true with "preventive stains" for potential coronary disease as people age. Patients are boxed into "guideline" numbers that seem to change on a regular basis and don't adequately apply to each patient on a "one size fits all" approach.
Doctors do not offer the patient a few minutes to really talk about their daily health and concerns. Rather, important information that the patient attempts to share and is willing to offer is often dismissed. The skill of an honest conversation has been lost.
Patients need to say "no" to "preventive medications that aren't adequately discussed.
9
I have a doctor friend who explained to me that to satisfy the requirements of his medical group he must see thirty patients a day. I invite you to do the math.
1
Thank you for your commentary. I think there are two points one would need to consider if the problem you clearly are taking note of could be fixed. The first is the financial motivation for this emphasis on diagnosis and medicalization. Pharma companies require increasing diagnoses to justify their marketing and costs of drugs for more and more conditions. Insurance company's require diagnoses to justify payment of services and treatments, medication of otherwise [psycho and physical therapy, for example]. School systems require diagnoses to justify the costs of services for needy students. None of this is necessary as such but becomes so because people need to pay for things and other people or companies need to make money. Second, but perhaps no less important is the way our culture has been evolving in its self-understanding and way of coping with problems. For better or worse, there is a cultural trend away from religious, moral and legal understandings of our problems to medical ones. As a society we like fixes that are easy if possible and that dont make us responsible or culpable personally. We like 'better living through chemestry'.. A pill for pain, another for productivity, longevity and youth in a bottle, maybe even happiness..... Doctors being more careful is well and good but the broader issue you touch on cannot be fixed without addressing these economic and philosophy of life issues.
7
Much of this can be traced to the advent of Direct to Consumer marketing. We now know of people with ‘unpronounceable’ illnesses and Wonder Drug X that can cure that problem. In the advertisements you see all these conditions having a joyous life after taking these meds. Who would not want such joyous life!
14
While I don't disagree with the overall premise of this piece, it is disheartening to see rising ADHD rates (and mental health diagnosis escalations) used as an example. These conditions are NOT medicalization of everyday challenges -- they are real, profound difficulties that impeded children opportunities and paths to success. Most of all, they have evidence-based medical treatments. When a child can not see the blackboard, you don't make them sit 6 inches away -- you give them glasses. Medication does the same for children with ADHD.
Additionally, a public health professional should understand that rising rates of disorders can be linked to other causes aside from societal changes. Recent research links shows nicotine can cause epigenetic changes that may lead to mental health and cognitive issues, such as ADHD. Consider that the current generation of ADHD children had grandparents in the nations largest generation of smokers.
As a family that deals with ADHD, along with other mental health challenges, PLEASE stop trotting out these disorders as problematic. Like any medical condition there are misdiagnosis, but it is hurtful to those dealing with the condition to have it constantly touted as over diagnosed. It belittles those working so hard to change the public's understanding of the disability.
23
@amyb. Thank you. As an older woman with off the charts ADD, I hear this all the time. Believe me, ADD is real.
2
@Been there
1. ADHD is undoubtedly real
2. ADHD is undoubtedly over, not under diagnosed
3. There is of course a spectrum; and society, media omnipresence, marketing , modern parenting and cultural norms “my kid has to have a smart phone” hopelessly obscure the real incidence and more importantly exacerbate the problem.
4. It would be very helpful to pateints, providers and insurers if ALL kids got screened , rigorously, for ADHD but that the criteria for the diagnosis were much more robust, reproducible and standardized. We have the obvious paradox today of far too many seriously ADHD kids from poor minority backgrounds underdiagnosed and undertreated, and failing in school, and yet far too many affluent kids overdiganosed and accessing lowered academic standards to get A’s.
As a long-time pharmaceutical rep, I may have more awareness of medical matters & the medical community than the averade person. However, I feel as patients, we bear the responsibility to manage our own medical care.
We don’t have to accept every medication that is offered. We must decide for ourselves, what alternatives to medicine may be best for us. We need to be aware that all medicines have potential side-effects (easily discovered by a search on the internet), and weigh costs and benefits. It is our body, our health; as patients we need to step up as a participant in our healthcare.
15
@Joan You shouldn't rely on internet searches to discover potential side effects of prescribed medications. These should be discussed with your doctor AND pharmacist before even taking them.
1
An individual’s illness/sickness is concrete - real.
A disease diagnosis is an abstraction, not a concrete reality. (It is said that the notion of “disease entities” was first put forth by Dr. Thomas Sydenham in 1676 to improve the care of patients.)
However, new diseases have been broadly promoted by companies seeking to profit from their creation and popularization.
An important question is - Will the proposed diagnostic label likely to yield benefits for patients or only profit for vendors?
10
Such a great article and one that resonates personally with me. I was diagnosed with ADHD at 13, depression at 15, and bipolar disorder at 17. From my teens to mid 20s, I was on multiple medications (sometimes as many as eight), and my mood was incredibly unbalanced. Finally, I found a psychiatrist whose philosophy centered around treating mind, body, and soul. Under his supervision, I reduced my medications to three and implemented a strict lifestyle regimen of therapy, prayer and meditation, exercise, low stress, and no alcohol. A few years ago, we wondered together if I was in “remission” and began a plan to taper off my medications. I’ve been off meds and thriving for two years now.
This will not work for everyone who had received a diagnosis of bipolar disorder—it’s is a serious disease that can be devastating when left unmanaged. That said, this course of action worked for me. I was lucky in many respects:
1) I found a doctor who treated me as an individual and not as a statistic, and 2) my family’s support and socioeconomic status afforded me the means and opportunity to choose the doctor I ended up with and take medical leave from work and school when needed.
I hope that patients come away from this article with the courage to question their course of treatment for any disorder and that doctors come away with a renewed desire to empower their patients and consider less invasive (and often cheaper) lifestyles treatments before prescribing powerful medications.
17
@Julia Daniels I was given Xanax for 16 years; yes, that's right, SIXTEEN YEARS! Only the plethora of withdrawal problems that hit me when I went "cold turkey" pointed out to me the dangers of this drug. Anyone on benzo medication should check benzobuddies.org to have their eyes opened. These meds should only be used short term, as I painfully found out, and there is a long, tedious withdrawal taper. I don't even think my prescribing doctor was aware of the inherent dangers.
4
@Julia Daniels
Julia this is truly wonderful. I hope you can find someone involved in medical research to tell your story to. This needs to be heard by many many people.
If at any point the time feels right for you, please do share this. If not, I understand.
1
@tornadoxy
Wow, 16 years? I was prescribed benzodiazepines for five years—I can’t even imagine 16. Going off of them was one of the hardest things I’ve ever done. When I decided I didn’t want to take them anymore, I was also advised the “cold turkey” method (under medical supervision and with the use of phenobarbital to prevent withdrawal seizures— note that alcohol and benzodiazepine withdrawal can be deadly if undertaken without medical supervision), and it resulted in a very deep depression and severe rebound anxiety. It probably took me about a year to stabilize. Again, every person is different, but from my own experience, I’d limit or avoid using that class of pharma as much as possible...
4
For the longest time now, we have been encouraged to participate in what I call preventative medicine. For we commoners, that entailed at least having a yearly physical. That entailed usually increasing testing, even invasive procedures. Regular scheduled colonoscopies, PSA testing which often leads to biopsies, EKG's, for the ladies certainly Mammograms etc etc. Often complete CBC's usually will find something to encourage a prescription for some medication. Cleveland clinic has reported the average adult American, takes 5 prescription drugs. Blockbuster meds are rapidly being approved, so one would expect that number to grow. The new Sprint guideline for BP, reportedly added 25 million Americans as candidates for a blood pressure cocktail, ( typically 3 pills). I have noticed the biggest challenges for a patient is the lack of co-ordination among too many physicians, all of who have little time available for patients. Saw my lady GP this week. A fine fine GP , her eyes met mine seldom, as she starred head down at her tablet computer reviewing issues, she didn't have time to discuss. What are we patients to do, in our anxiety for that so called silver bullet.What is bothersome is it seems most medical research is treating conditions not curing them.
12
@ Dan Green
Well said. As far as I can tell, my (concierge) primary caregiver runs her eyes down the right hand column of my annual blood work, and, whenever she discovers an anomaly, something outside the “normal” range of results, prescribes a medication - which I frequently refuse to take, leading to considerable friction. This is what passes for medical practice,
1
As a psychiatrist, I agree with most of the commentary. Whenever a patient comes to my office, before medications are discussed, we review sleep, diet, exercise, mindfulness-meditation, relationships, spiritual-religious beliefs, stressor identification, supplements, and possible underlying medical conditions, eg, hypothyroidism. And if the patient decides, by making an objective, well-reasoned, well-informed decision, that a trial of medication is in his or her best interests, at this moment in time, then the operative words are 'start low, go slow, and come back feeling like yourself,' so then you can tackle the sleep, diet, exercise, relationships, stressors . . . .
28
@rpmars
Wow, you’re rare. As a psychologist, i have helped patients in a variety of settings, including hospitals, mental health clinics, schools, day treatment centers, etc to reduce or eliminate medications (even for “purely” physical pain).
But quite often, there is enormous resistance even AFTER it is demonstrated the patient is doing better off the meds than on them!
4
Very well said. From my perspective as a psychiatrist the push to diagnose and medicate comes from patients. It certainly does not come from me. I'm forever trying to explain that it's normal to feel such and such. That doesn't mean that the sufferer should be turned away at the door. Nothing of the sort.
Another aspect of this issue is the way people are insulted when told their symptoms are psychological in nature. I fail to understand how that is insulting. It's should be great news to not have a life threatening physical illness. It should be a relief to know that the problem is, basically, some variety of stress and depression.
We always must keep in mind that seemingly psychosomatic symptoms could be the first signal of a developing physical illness, and that there are indeed conditions medicine does not yet know how to identify.
We should also be less hesitant to name things as they are, including when the problem is psychological and psychosomatic, the way a person's mind and body react to life's hardships.
A complex web of causes led to a decline in the role of the physician as listener, healer, consoler. Once we are reasonably reassured that life and limb are not directly threatened by a physical cause, turning to the mind to seek healing is a wonderful thing. Not bad, not shameful, but wonderful. It's sad that physicians are not allowed to provide this healing. Physicians in general, psychiatrists specifically, are unwanted as healers of souls. Real shame.
30
@PsycheDoc
"It should be great news to not have a life threatening physical illness. It should be a relief to know that the problem is, basically, some variety of stress and depression."
I love it when a patient asks, "Do you think it could be stress, Doc?"
Yes, yes, YES. It could always be stress, and very, very frequently is, but so many people would rather undergo a $20,000 cardiac workup than hear that they need to relax a bit more.
You've got it right, ∏Psy.
19
@PsycheDoc But what about when you have tried all the sleep, exercise, journaling, meditation etc and continue to struggle and have a poor quality of life? I spent years trying all those things diligently and going to therapy and got no where. Once I relented to try medication, my life changed significantly and most of all I became a better parent to my children who needed me. Yes, life is hard, but I also don't think people should struggle endlessly before being given the opportunity to manage what may be a chemical imbalance (as it was for me).
25
@amyb first, there is no such thing as a 'chemical imbalance'. It's a myth. We have no idea why psychiatric medications work or why they (often) don't. This is true of many medicines in general. That doesn't mean we shouldn't use medications.
Second, what you describe is 'treating by the book' rather than listening to the patient. There is nothing wrong with using medication when needed. Not to quash imaginary diagnoses but to help people feel better. That's the art of medicine. Of course you shouldn't struggle endlessly, the whole purpose of going to a doctor is to get help.
I'm finding this hard to explain in a comment, so I hope that clarifies things a bit.
15
I see the pill pushing mostly from my doctors.
I'm a cancer survivor. Chemotherapy was a necessity, but the repercussions from it - even years later - are varied and diverse.
I developed osteoporosis. Doctors solution: go on a bisphosphonate. My solution: start intense weight training, which has kept my bone density stable.
I developed gastric reflux, which I never had - even when pregnant. Doctors solution: PPIs. My solution: change diet and eating behavior, which keeps my reflux under control.
I've just developed pre-diabetes. I'm a bit freaked out, as I'm thin, eat healthy, and exercise. Doctors solution: don't worry, as you can always go on Metformin if it gets bad. My solution: tweak diet to be low glycemic and see if my behavior change for this diagnosis will be as successful as my other two.
The medicalization of symptoms is easy if doctors know that they can easily prescribe a pill that may alleviate symptoms. Of these diseases, only gastric reflux has a subjective diagnosis. The others - cancer, osteoporosis, and pre-diabetes, have clinical tests that give a quantitative value.
I'm the oldest of my friends, and also the only cancer survivor, so I'm the first to develop these diseases. I can't tell you if my attitude - change behavior to avoid medication - is normal or not, but I suspect that its not. I've learned the hard way, however, that every pill comes with a side effect that might needs its own pill.
Better to avoid medication when possible.
76
The current state of Medicine in America is quite simply, a disaster. One in Seven Americans on Psych Drugs courtesy of poly pharmacy of Modern Medicine. Whatever happened to listening to the patient, Freudian, Jungian analysis, interpretation of dreams and old fashioned psycho-analysis? This is gone, and psychiatry is now a drug based enterprise: This is a Disaster. Drugging of Children: Modern Pediatrics with its overdiagnosis of ADD/ADHD and over-use of amphetamines and atypical antipsychotic drugs in children is a Disaster. The exponential increasing autism is challenging the capacity of our schools, hospitals and social services. There is no known cause and no cure. This is a disaster. Drug Industry has paid out 35 billion in criminal and civil violations. This is a Disaster. 10% of New Drugs are “Bad Drugs”, initially FDA approved and later withdrawn from the market when problems are found. Another 10% are given black box warning. This is a disaster. Howard Kunstler explains why we have Disaster Medicine in America in his article entitled: Rain Dance: “So, the current product of (Health Care) debate in the US Senate is just a scheme for pretending to reapportion the colossal flow of grift among the grifters.“ For more see: https://jeffreydachmd.com/2017/06/disaster-medicine-america/
13
@Jeffrey Dach MD
I quite agree, and would add this: overprescription of antidepressants for older patients seems to be rampant. At least three doctors have prescribed this for me over the years. I had to discard the pills in short order, each time. They may take the edge off grief, but at the same time they take the edge off our intellect, and that to me is intolerable. Whatever happened to the concept that true grief is an integral part of life, and cannot be “cured” by a pill?
10
@Jeffrey Dach MD
I would encourage everyone interested to read, " "Ending Medical Reversal" by Vinayak Prasad, MD. MPH and Adam Cifu MD. If you take it all in, a reader can become familiar with what patients face. A key point in the book is, trials are a better barometer of what works as opposed , to this should work here take this pill.
@Gloria McFarland
I so agree...true grief is an integral part of life and cannot be cured by a pill.
Life presents us with challenges for which we need inner strength and fortitude. This sounds so retro, I know, but it has served me well for 75 years--through the loss of my mother when I was a child and subsequent family traumas. Nary a drug here--just choices to live in hope and the discipline to do that. The Serenity Prayer has been a lodestone.
2
There are many "conditions" that are basically just normal life. For example, having an upset stomach after a heavy meal or occasional constipation is normal, but there are lots of people who would like the diagnosis of IBS (patients, pharmaceutical companies that make drugs to treat this condition, the doctor who wants their patient to have an "answer"). Some people just have GI systems that are more sensitive to the types of foods they eat, whether they are anxious, whether they've exercised that day. It's just how it is. Once something has a name, there are suddenly drugs to treat it.
12
When was the last time that a doctor actually examined your body other than a cursory heart/lung listen?
My annual exam no longer includes an examination of me. I go for tests. I go for the "exam" to discuss test results. Why not do that by text message? Why go to the office? We could save lots of money.
16
@Whatever
There is HIPAA compliant text service available (I use it with my doctor). So far it has been awesome. I have been with my doctor for over 5 years now and he has a private practice. He just switched his entire practice to direct provider-to-patient care with one monthly fee and all services included. One of his main reasons for this was to be able to provide this texting service to everyone in his office. This set up is definitely the exception rather than the norm. In Seattle the cost of living is very high, so my decision to stay in his practice did not come lightly and I have had to make sacrifices in my budget. While I realize not everyone might have the same privileged to afford the monthly fee, he bypasses insurance entirely and by my calculations I will still come out on top financially in the end. I should mention I have a couple of chronic diseases so I need relatively regular monitoring.
6
@AC
Good comments. Many older Physicians still gather all the reports on a fax machine. GP's usually run their practice , (as is understandable) , as their own livelihood, what ever works best for them. The patient is second. Most Doc's complain, as victims of their own professions newer operating model. How you could have a profession that doesn't allow enough time to getting your job done, would have most commoners, either on welfare, or looking for a new job.
@Whatever And because the electronic medical records requirements, I find my doctor keeps his eye on the computer screen because he is busy typing and doesn't even look at me when I try to discuss my condition.
2
Irritable Bowel Syndrome is not "part of the normal human experience. " nor have I read or heard of an explosion of Irritable Bowel Syndrome Diagnoses, over recent decades.
Clinical Depression is not part of the normal human experience,
while grief following the death of a loved one is.
It's true that there has been such. an increase of diagnosis of ADHD and Bipolar Disorder, which is likely to represent. an increase in diagnosis, and not an increase of either condition.
17
A thoughtful piece, especially on the medicalization of young children, which seems so focused on controlling their behavior to please adults
It is important not to overlook the real need for medication, as well as periodic reassessment. Medication can act as a bridge to better habits (although the “better habits crowd” makes me itchy; they smack of moral superiority and a “I’m better than you/you are weak” puritanical streak that is part of American culture.) Sometimes meditation will not cure ailments, reduce blood pressure or reduce it quickly enough to avoid a stroke. During a stressful life event medication is entirely appropriate and called for, even though mental health is heavily stigmatized.
What concerns me is that certain medications become stigmatized to the point of “public enemy #1” and are denied to those who need them. There are good people in pain who are denied pain relief because opioids are the current curse. I have watched someone post-abdominal surgery refuse medication for acute pain, significantly prolonging her recovery from weeks to months. Yet she is proud she refused” pain medicine” and makes no connection between her prolonged recovery.
No one medication can or should be so demonized unless it causes causes significant harm. Sprained ankles, by and large, don’t need OxyContin( or casts, an earlier convention), but I feel for people who suffer needlessly when all they wish to function, not get”high” or break laws.
14
Diagnosis is complicated for disorders like fibromyalgia and chronic fatigue syndrome and often include a variety of symptoms, including irritable bowel syndrome but few good remedies.
I've had fibromyalgia for about 15 years now. I was fortunate it was diagnosed quickly, on the first visit to my doctor, who then sent me to a specialist. Most people drag on for years without a diagnosis.
Not every disorder needs active treatment. I tried Lyrica, but it caused huge weight gain (20 lbs.) and loss of hair. Today, i find that exercise and Tylenol are a better treatment for me.
As for IBS, more fiber (or in the case of some vegetarians, less) is often all the treatment required.
Just knowing is often enough, combined with OTC remedies.
4
@Barbara
More fiber didn't do a think for me when I had IBS.
I was violently sick to my stomach nearly all the time,
and lost so much weight such that I was skeletal.
4
@Barbara
To reflect another comment from DJS, if you have undiagnosed inflammatory bowel disease (Crohn's, ulcerative colitis) extra fiber can be a death sentence. Also, many people with IBD experience IBS, and getting a proper diagnosis can take years (as you mentioned). For instance, before I was diagnosed with IBD a GI told me I had "college student" syndrome and the recommendation was to eat >40g fiber/day. Upon following this advice I lost over a third of my body weight in just over 3 weeks.
I agree with the general sentiment of the article, but I also think people that are in touch with their body often know when something is wrong, so it is important to find a doctor that takes the time to listen to your concerns... not just one that will write a script and send you out the door.
6
@DJS
I was also diagnose with fibromyalgia and IBS. A gluten free and limited dairy diet has helped enormously. Observing and avoiding triggers and maintaining a healthy lifestyle keeps it in check so that I can keep,active.
2
Completely agree with the issue raised by Dr. Khullar. And it seems to be very much a US problem where the tremendous influence of pharma and its lobbyists leads to overmedication. Also, the barrage of advertising that you are exposed to on TV ceates a society of hypochondiracs who will imemdiately have all the symtoms of the disease du jour and demand immediate cure in the form of meds.if their doctor does not offer some medicine for this oft imaginary disease, the “patient” will go and seek out one that will indulge him.
9
@Lorca
Agree re the hypochondria comment. Running to the doctor often, and being subjected to test test test, can turn anyone into a hypochondriac . Todays Physician's model, is to load their tablet computer with test results. Often resulting in some drug being prescribed .
1
This is just the kind of overly measured, offend-no-one article that ensures no real change will be made. Just say it—this trend is terrible for our species. You hit on one solution though—lifestyle changes in place of drugs. Amen!
9
The US is one of only two countries which allow direct to consumer advertising of prescription drugs. (New Zealand is the other.) Patients see a new drug advertised and are encouraged to ask their doctor to prescribe it. That request can suck up a major portion of the average 15 minute visit with their health care provider. How does this make sense?
35
This essay starts a conversation about how we are both oversold and underserved by our current medical system, but it does not provide much insight as to how to improve the situation. There are hints (longer appointments with doctors, more lifestyle management)...but how do we steer the system to provide those things? Otherwise, the suggestion seems to be that everybody should just 'suck it up' and quit complaining. We are both encouraged by the profit takers to "medicalize" the everyday and then shamed by the social analysts for doing so. Where the guidance for the average citizen on how to navigate all of this?
4
@K.
Agree. Net of our system is best explained, by the % of GDP that is generated by , the four pronged medical establishment. Pharma, the AMA, Insurance companies, and for profit Hospital corporations. Like automobiles and fossil fuels we depend on these entities for our economy. Just having healthcare and a drug insurance is a major occupation for all of us.
3
As a physician in a surgical sub-specialty, being meticulous in my work is essential. Even as a child, everything on my desk had to be arranged perfectly. I recently saw a TV program where a man went on disability for OCD (obsessive-compulsive disorder). He had many of the behaviors that I have. I am grateful that I am organized and meticulous. The man on TV considered himself mentally ill with the same signs. Go figure!
32
@Laserlady
Well, I guess the difference would be if it's actually painful for you to have something disarranged. If you prefer it neat, but can handle temporary disruption without pain then you're probably not suffering from OCD. You're just orderly and organized.
7
@Laserlady
I was and still is just like you, over organized but I love it. Agree sometimes I try to be so organized it causes some confusion, but I mastered that.
1
@Laserlady. And I am the opposite - very disorganized with major ADD. But if I had the chance to not have ADD, I wouldn’t take it. I think quickly, come up with innovative solutions to problems, make connections that others don’t. It does have its advantages.
There's plenty of speculation here and hardly any evidence.
8
Sometimes you have a bunch of vague symptoms that haunt you for 20 years like fatigue, joint pain, hands and feet randomly falling asleep, dizziness, severe lower back pain, to name a few, and eventually you get diagnosed with something that explains it all.
This happened to me. I found out I had celiac disease at age 37 after suffering with these things that doctors didn't seem to take very seriously or seemed to consider normal. I went on the prescribed gluten free diet, and every last one of them completely disappeared.
From my perspective, we aren't quite testing for the right things fast enough, and are quick to wave away symptoms like these, especially when it's a woman making the complaint.
49
What’s of note is that all of the examples given are psychiatric diagnoses. Since the brain is markedly complex and the biological basis of mental health disorders is only now becoming better understood, this article speaks more to the author’s misunderstanding of brain health and modern advancements, rather than identifying an actual societal issue.
11
@LTJ
I hadn't been aware that Irritable Bowel Syndrome was a psychiatric diagnosis. I was diagnosed by a gastroenterologist.
8
@DJS
Problem with IBS diagnosis is it is one of exclusion..and their is pof course no targeted therapy or precise chemical bookmarked to track. One certainly CANNOT exclude that it has a major component, or is exclusively, “psychiatric”/emotional etc.
I'll add a few more thoughts based on my own experiences. First, I've found that the older I get, the more likely I am to "worry" about symptoms I probably would have ignored when I was younger. Not always a bad thing but it can contribute to over-medicalization. Second, where I live the access to medical care, including specialists of all kinds, has exploded in recent years, and with on-line appointment scheduling it is incredibly easy to get in to see anyone, often that day or the next; therefore, it is also all too easy for me to act on my "concerns" rather than wait to see if I get better with time. Finally, in my experience the medications that are prescribed often produce side effects that can be as unpleasant as the original condition, which might very well have cleared up on its own. My primary care doctor is very good about prescribing "patience," but I have had to learn to follow her advice.
15
We HAVE overmedicalized much of life with serious consequences. A recent JAMA study indicts 200 commonly prescribed medications, which may cause the side effect of depression. One third of adults take at least one, such as beta blockers, anxyolytics, PPIs and ibuprofen. Over-diagnosis leads to overprescribing which leads to other problems, including galloping rates of depression. As a licensed naturopathic doctor (ND) and in close communication with prescribing physicians, when indicated, I support patients reducing or discontinuing prescription drugs. We create plans predicated on understanding of underlying pathology, sustained lifestyle modifications, evidence-based natural medicines, and gradual, guided reduction of dosing. Many drugs are essential and brilliant and work perfectly. Or, side effects are managed because a worse problem is avoided. Lifestyle and natural medicine have a powerful track record of efficacy for many of these newer diagnoses.
Careful assessment of diet, alcohol consumption, physical activity, stress and more is essential. For the motivated patient, NDs offer a whole new toolbox with powerful, individualized care for both prevention and for addressing diagnoses including fibromyalgia, depression, insomnia, anxiety, chronic infections and allergies, hormonal imbalances, cognitive decline, digestive disturbances, auto-immune disease, and give direction for those patients who have no diagnosis yet continue to feel poorly.
26
@amy rothenberg ND
As a patient, if you want a health care practitioner who will have a conversation, take an in debth history, and actually listen, you want a ND. NDs heal.
12
Follow the money. It’s the outside interests and agenda that taint modern diagnosis. Just to stay with ADHD and Pediatric Bipolar. ADHD is relatively common but both over and under diagnosed due to structural issues - lack of child psychiatrist and ease of treatment-the Pediatrician has the same time slotted for the ADHD as a cold. Pediatric Bipolar is an issue of Pharmaceutical Companies co opting a rare disorder for mutual benefit —allowing provider, insurer and government social services to “treat” complex social and psychological issues via solely medication. If providers had the “luxury” of proper time and effort to diagnosis- ADHD would continue to be common while Pediatric Bipolar would once again be a “rare psychiatric disorder”.
11
Solid research shows that children as young as toddlers can be clinically depressed (anhedonia, or failure to experience joy, and irritability are red flags) and that children can have clear episodes of mania and depression meeting all the criteria for adult bipolar disorder, usually rapidly-cycling, and often in families rife with mood disorders. Children as young as six were being treated successfully with lithium in Sweden starting in the 70s. early treatment does not cure mood disorders but can bring great benefits. It is ignorant to say these disorders are imaginary, just as schizophrenia and autism were blamed on mothers in years past. Mental illnesses begin in childhood and early intervention is the best path...with psychotherapy, parenting support, nutrition, and often medications.
9
I dealt with mild general anxiety, insomnia, and what would probably know be diagnosed as social anxiety, since childhood. It made some things very difficult. But this was before there was a lot of medication and treatments for that sort of thing. So, the way I dealt with it was through forcing myself into social situations to "practice" being more comfortable, incorporating meditation and other relaxation practices in my life, and also positive thinking techniques and other changes in mindset to help me deal with anxiety.
As a result, this previously anxious and non-confident young adult now has far more self-confidence and self-acceptance than most adults I know. I'm comfortable pushing my own comfort zones, and know how to shake off failures or social slights.
I don't think I would have developed these skills if the first line of defense was medication. Maybe medication would have had quicker results, but I think the longer road resulted in better and more permanent results.
91
You cite evidence that newly diagnosed fibromyalgia patients may be more satisfied with their health and have lower future costs. Looking at the article linked, those conclusions are quite a stretch--they are based on a mere 18 months of observation in a tiny cohort of 72 new fibromyalgia patients.
Many studies reporting on fibromyalgia are of poor quality, and prevalence estimates for the general population range from 0.2 to 3.6%, a 16 fold spread ( https://www.ncbi.nlm.nih.gov/pubmed/28743363 ; Prevalence of fibromyalgia: literature review update, 2017). Even if one stipulates that the 2010 criteria for the diagnosis are better than in the past, they have not been used that consistently in the office.
Maybe patients do feel better getting the name and maybe physicians feel better giving it to them. No doubt medicalization of symptom complexes leads to over-treatment. In the case of fibromyalgia this can lead to substantive harms: https://www.mayoclinicproceedings.org/article/S0025-6196(16)00102-6/pdf ("Opioid Use in Fibromyalgia: A Cautionary Tale," 2017) AND https://www.amjmed.com/article/S0002-9343(11)00494-3/pdf ("Opioid Use, Misuse, and Abuse in Patients Labeled as
Fibromyalgia," 2010).
5
Sometimes, doctors go too far trying to give a diagnosis instead of saying, "I honestly don't know what's wrong with you." They refuse to listen to patients who might more than they do (because it's personal to them).
In June, I began to exhibit symptoms of Tourette. I'm 64, and it's extremely rare to develop sudden onset of Tourette, but it does happen. A chart review by Columbia Presbyterian revealed 20 older patients who did develop the disorder in a similar way to me. What did they have in common? They had all taken cocaine tainted with a known carcinogen and neurotoxin (according to the EPA), NDMA. I never touched cocaine, but I had been taking generic valsartan. In mid-July, the FDA withdrew generic valsartan from the market because it had been tainted with NDMA. Aha, the reason. But most doctors (especially those with their own agendas) didn't know that. Only one MD made the same connection I did.
I even went to Mayo Clinic in Phoenix. That MD definitely had an agenda (Parkinson) and I didn't fit it. So, he dismissed me with a diagnosis of exclusion (ie, we don't know what you have but we have to call it something), functional movement disorder. It's a TOTALLY phony diagnosis, according to key opinion leaders.
Doctors are as guilty as the patients you deride, maybe more. I have more respect for an MD who says, "I don't know," than I do for an MD peddling a phony diagnosis of exclusion. As a result, I still suffer, but MDs, like the one at Mayo, really don't care.
56
Physicians find it easy to start prescriptions but difficult to stop prescriptions. I currently work in an ALF. Almost every patient regardless of age or infirmity has been placed on PPI.s,statins, Vitamin D multiple antihypertensives and steroid creams. I have been reviewing charts and discontinuing these medications although the nursing staff is not happy. The problem is that every specialists adds a drug specific to their specialty and assumes there is a primary care provider to coordinate all of the specialists medications.Not true
61
As a physician, I believe this article raises one of the most important medical issues of our time. I recently completed a fellowship where I spent significant time in a private clinic. The pharmaceutical reps surrounded the docs day in and out, gave out ice creams and lunch during the day and offered dinners some nights as well. They were pushing name brand drugs that were sometimes hundreds of time more expensive (and did not work better) than some generic counterparts. Pair this with the incessant demand to treat every symptom with a pill and the pressure to give in to unreasonable patient demands for medications is a recipe that forces doctors and to be complicit with pill pushing. Inappropriate prescribing by midlevels compounds the problem. Some people need strong lifesaving drugs to treat their medical problems but the idea that one fourth of out teens need a prescription medication is a symptom of a very ill country. Thank you for writing this article, it’s truly one of the pressing medical issues raised by NYT this year.
116
@FM
Thank you for your thoughtful comment. In my practice we kicked the pharmaceutical reps out 20 years ago. I educate myself with The Medical Letter and UpToDate, never from a meagerly trained salesperson whose interests are not aligned with my patients'. A more challenging problem is knowing when the "expert" at the national meeting is a shill for the pharmaceutical industry.
3
A collateral problem created by the profusion of diagnoses is the practice of placing patients on drugs without any plan for withdrawal.
Any drug that is taken for a lifetime is equivalent to chemical surgery, and the patient's adaptations to that drug often involve serious systemic changes that may not be reversible even with a planned withdrawal program.
The rising incidence of patients who are on several lifetime prescription drugs -- e.g., cholesterol, blood pressure, depression, acid reflux -- is a health hazard that both doctors and patients should be addressing.
45
What this article fails to mention is the role of direct to consumer advertising of Pharmaceuticals and access to self-diagnosing websites like WebMd
30
If indeed 25% of children in the US are continually on prescription drugs just to function "normally,"- that IS alarming. But It was alarming when children's conditions, especially behavioral, cognitive and and "psychological" were not recognized, and children were labeled or treated cruelly, or left behind.
In many conditions - ADHD and fibromyalgia being two - there ARE a host of adjunct approaches which emphasize activities and support, and coping strategies, but those require training and person to person work -- which isn't covered for many families. In fact, ADHD is an area where public health initiatives should be a primary way to approach the problem. When there are that many individuals diagnosed, parents need training or coaching, as do the children. Medications can help greatly, but work better only combined with strategies for working through their particular set of strengths and weaknesses.
AS for sleep problems: Is there anyone who doesn't suspect that insomnia is directly related to job demands, including long commutes, which make anything like a predictable, relaxed paced family life an impossible dream?
There are too many threads in this essay to pick up on. Too many for Dr. Khullar to handle other than superficially.
Still, the one thread which does carry through is that pressure to do something to "improve functioning" and do it quickly - or be left behind in the competition for good jobs and academic success-- falls on Drs. and patients both.
16
Big Pharma in the US is the pusher of drugs. Day in and day out we have to watch drug ads on TV and elsewhere. Clinical trial outcomes are written by industry. America is overdosed and it's costing us our health.
https://www.goodreads.com/book/show/220314.Overdosed_America
18
The biggest problem is the under-diagnosis of sleep disorders, especially sleep apnea. Sleep apnea rates are rising (10-20% in some populations over 40) but diagnosis rates are still at an abysmal 10-20%. People with untreated sleep apnea see more doctors, incur more health care charges and get labeled with more diagnoses---include fibromyalgia, migraine headache, hypertension, insulin resistance, dementia, ADD, erectile dysfunction, unstable angina, stroke (that occurs while asleep), chronic pain (due to suppressed endorphin receptors) depression and anxiety and obesity (poor sleep makes you eat more)--until some doctor thinks to ask "How do you sleep? Do you snore or stop breathing? Have you asked a family member if you snore or stop breathing? Do you get up two or more times a night to urinate? Have you checked your first am blood pressure to see if it is higher than your blood pressure later in the day? Do you have a family history of sleep apnea?" Once someone thinks about sleep apnea, then the diagnosis and treatment process can start. But, until that happens, sleep apnea is like a patient with a big ugly melanoma mole on his back who lives alone in a house with no mirrors--the patient can not possibly know what is on his back and he can not know what he does when he is asleep. Therefore, the doctor must recognize the signs and symptoms. But the medical profession is still very bad at picking up sleep apnea in all but the most extreme cases.
21
Thank God for this educated opinion which sums up exactly where this nation is with its penchant for "over-doctoring."
6
You lost me when you said ADHD was newly medicalized.
9
"$80 billion a year," is mindboggling when considering an ongoing, ever-expanding process -"medicalization"- which some literature have labeled as "disease mongering."
Consider: any diagnosis, be it of people's health/disease; objects (metal fatigue); states of BEING (economically deprived, discriminated against, ec.) is a judgment based on the collection of relevant materials in order to make a necessary decision(s). Based upon "proven" criteria. There can be, and are, sources for known as well as unknown "flaws" all along the dynamic, complex, multidimensional ways. With regard to diseases one should be considering three minimal factors. A useable diagnosis, for effective treatment, if necessary, and possible, includes the source of the disease. Its process. Its prognosis; if treated or not. There are diseases whose "causes" aren't known. Understood. And as we cope with the complexities of "causality," we are often challenged with outcomes which are "associated with" but not directly caused by. As well as existing outcomes whose cause(s) and associations are not understood. In any predictable way; thus limiting effective prevention. Both "alcoholism" and the use and misuse of selected "drugs" have been diseased in recent human history. Which can minimize stigmatizing fellow beings. Unique treatments for diverse "alcoholics" and "substances use disorders" are a myth. These people receive the same "therapies" as non-users.Words. Meds. Etc. Diagnosing is an industry!
Overdiagnosed and medicated, maybe. I might be one of these cases, and I suspect that lifestyle changes could help. But tell me, where in the capitalist cycle of commute, work, commute, sleep, repeat are we supposed to live these lifestyles?
78
Years ago I was having a lot of unexplained problems I was offered a choice of diagnosis: IBS or fibromyalgia. Neither was correct and neither offered real treatment but both were considered "pre-existing conditions. The offer clarified to me that male doctors think women just bit-ch and their reported issues are to be belittled and ignored. Thanks for making a cynical consumer.
32
I looked at my medical file and discovered I had several diagnoses of chronic problems that had gone away. I'd had trouble coping after my mother died, got a diagnosis depression and a prescription, which, after a while I stopped needing or taking. I'd had some digestive issues, that went away, too. They were still in my files as chronic years later.
36
I've been trying all year to get my doctor to remove problems that were ruled out from my chart, without success. Little things that aren't really important, but if I weren't a doctor myself, it might make me wonder what else isn't right about my care.
30
On a recent visit to the regional
Medical center, the medication list indicated that I take doxycycline. I don’t “take” doxycycline the way I take my daily statin; I took it once last summer for a tick bite. Don’t these systems differentiate between a single short course for a one-shot situation and daily medications for chronic conditions? I felt less confident during my visit after that.
35
@Julie Zuckman’s
Getting short term meds removed from your medical file is a big problem. At every primary care visit, I tell the medical assistant that, no, I'm not still taking a med that was prescribed for 7 days for a problem I experienced 5 years ago and that hasn't recurred. Next visit, the same thing. No one ever actually updates anything. It's like the questionnaires the doctor's office has you fill out prior to being seen. I've never had a doc actually look at or respond to one.
57
Dr. Khullar wrote: "An important step forward may be putting more emphasis on nonprescription remedies. For many medicalized conditions, lifestyle changes are often just as effective as medications, if not more so (and don’t come with side effects)."
I agree wholeheartedly. Eat a better diet (plant based whole foods is one of the best -- no animal products and minimal to no processed "food"), exercise, don't smoke or drink alcohol. It doesn't make much in the way of profits, though.
33
I would say that the bigger problem is the underdiagnosis and treatment of conditions in Black, Hispanic and other minority populations. Women are still ignored, belittled and dismissed with documented bad consequences by the medical care system. I am much more concerned about these issues than the ones brought forth in this article.
72
Diagnoses can run the gamut from being highly correlated with accurately identified symptoms and patterns of progression to an ill-defined problem where no medical practitioner really knows what is going on and all tests are uninformative, in other words, idiopathic disease.
Without a diagnosis, there cannot be a legitimate treatment plan, only a good placebo effect or perhaps through serendipity, an effective though unjustified treatment.
The best doctors in the world are the best diagnosticians and there are very few such physicians but most of them are internists.
13
@Emergence
How I wish I could find one of those excellent diagnosticians, as I have a condition that is extremely visible, which has defied diagnosis by some of the top doctors in New York, included professors of medicine at major teaching hospitals. One day, I awakened with my skin covered with itchy designs and patterns. Since that day.
anything that exerts the slightest pressure on my skin,
such as clothing, a towel wrapped around me, even a bandaid that is pressed into my skin by a sock, or on which my skin exerts the slightest pressure, such as my face on my pillowcase, form mirror imagine itchy grooves, patterns or indentations.The response I have received from every doctor is some version of : "I have never seen anything like that in my life," Or "I have NO idea what that is." Doctors have grabbed colleagues into the room, circulated photos
to other dermatologists allergists and other specialists, and none has ever seen anything like it.
While there is no diagnosis, and therefore no real treatment ,there is more than a placebo, as anti-histamines can turn down the volume on the resultant itching.
It seems that I am doomed to spend the rest of my life, trapped inside, unable to wear clothing.
If you , or anyone reading this has any suggestions as to where I might go to search for a diagnosis and treatment, I would appreciate a suggestion. The Mayo Clinic is not accepting new patients. or accepting patients to it's waiting list. Thank you.
4
@DJS
Sounds like dermatogtaphia which is a sign of mast cell disorder.
3
@DJS
You lost me at “The Mayo Clinic is not accepting new patients.” Obviously this is not correct or they woudl go out of business, here is more to your story than indicated.
The pharmaceutical industry plays an outsized role in our medicalized society, and their tactics have become increasingly sophisticated. The industry advertises all too often on TV; plays an active role in which studies get published; choses which researchers to fund; offers financial incentives to academics and physicians willing to promote their products; and drives disinformation campaigns in the media. Without exploring the overreach of that industry, the medicalization of America cannot be understood.
75
Autism spectrum is a case in point.
10
@Peter Silverman. What are some of the desirable alternatives to autism spectrum?
What about insurance? Insurance won't pay for treatment without a diagnosis. That creates a strong incentive to create diagnoses.
137
@Mimi
Insurance also pushes for the least expensive option in treatment plans: often the chemical treatment plan is far less expensive than treatment in the form of visits to a specialist.
1
@Gloria McFarland Wow, you don't get the point. The fact that insurance PAYS but only if there is a diagnosis according to codes is the reason for more and more "diagnoses" - this has zero to do with what insurance pays for and the cost.
@Mimi
THAT is exactly what I was about to say!
Especially in the field of mental/emotional problems.
A diagnosis can be an immense help when one has to explain to an employer, a co-worker, a teacher, a friend, or anyone else why one cannot do certain things. However, medication is not always the best answer when it comes to solving the problems caused by the illness/handicap. There are times when, if a child is involved, all the people in the child's life need to get together to plan how to respond when the problem leads to learning difficulties, temper tantrums, or trusting behavior in the wrong settings. If it's an adult the same thing applies.
What I've experienced is that people are forced to go and get a diagnosis because of our society's increased reliance on the rigid enforcement of rules when it makes no sense at all. With the exception of a few people, most will understand why the rules are being bent for one person. Those who don't or who object need to be reminded that they too will need rules bent for them one day. Some of that is called getting older and needing help.
16
@hen3ry
Unfortunately, obtaining a diagnosis in order to obtain special privileges is being abused widely, in situations where there the individual does not suffer from the condition, but manages to pry a diagnosis out of a medical professional in order to gain special privileges.Specifically, a number of parents have convinced medical professionals to grant their children ADHD diagnoses in order to obtain extra time on exams such as college entrance exams. I know for a fact that this is done, as I know some of the parents and children who are involved. There is nothing wrong with these children. These parents want to give their children an edge over other children , and are harming the other healthy children who are not granted the additional time to complete college entrance exams, and other exams, given that these children are competing for entry at the same universities.
I could be wrong ,but it is hard to believe that there are so many children who suffer from ADHD, who are able to take AP classes ,gain admission to Ivy League Universities, and go on to earn doctorates, medical degrees and other advanced degrees.
9
@DJS, I know and I've seen it. Those parents make it much harder for people who are genuinely in need of the extra time or an accommodation. What's even worse is the resentment. When my brother needed an accommodation at our municipal pool you'd've thought the world was ending. People need to learn to be grateful that they don't need accommodations, that they are "normal". We might not like the handicapped parking spaces when we can't find a space but the flip side is that we don't need them and for that, I am grateful. I can still walk under my own power while others can't. Or I can take a test within the limits but someone else needs more time. It's part of life.
4
I had an adult son who chose to end his life after suffering with Primary Progressive Multiple Sclerosis. This disease has been around for many years. Our society , primarily government laxness and pharmaceutical companies, do not seek cure or causes. They are already too profitable, or in the case of government, ignorant in regard to the need for financial, global consortiums that will end the horror of these diseases. Imstead, normal life situations have become a cause for more profit through TV ads that only add to our dependence on drugs.
Treating symptoms is at best, a poor response since it often does not add to the quality of life. Instead, ads make us all think we have a disease which is actually called life.
Until our world seeks cause and cures for the real named diseases, we will continue to see suffering , addiction and suicide.
31
I am so sorry that you lost your son. Please accept my heartfelt condolences.
26
@Grieving Mom I am sorry for the tragic loss of your son and his suffering with MS.
9
@Grieving Mom
I am so very sorry to learn that you have lost your son, that and that your son suffered so terribly such that he felt he had no alternative but to end his life. I extend my heartfelt condolences to you.
9
I share the relief of the hairdresser when my physician and I made the decision that I did have fibromyalgia. It legitimized my complaints. Years ago I was having 2-3 day periods of malaise when I became almost non functional. It was difficult to communicate what I was experiencing when I had to call my manager to tell her I would not be able to come to work. She inquired about whether I had a fever, digestive issues, and other symptoms which would make my absence necessary. There was no name for this experience, no vocabulary to help others understand what I was experiencing. I continued to have periods during the day where I experienced the same malaise for two hours and for which I had to isolate myself in my office until it passed. When I was diagnosed with Major Depressive Disorder the primary symptom was a profound malaise with mysterious pains that would leave me prostrate on the couch. Even when the depression lifted somewhat, I had to create a daily life around this exhaustion and was left canceling appointments, dates, etc because of it. I designed my day to have a rest period after an activity. I didn't know to describe it to friends and colleagues. Having a real diagnosis that serves as a shorthand way to explain my physical condition and understanding it cannot be overestimated. No more was I a malingerer.
31
@Janet. Re: fibromyalgia—On the other hand, this newer diagnosis has become the go-to for doctors who feel too busy to do the homework on numerous other possibilities—particularly for women.
5
@Janet I am sorry for the tragic loss of your son and his suffering with MS.
4
@Janet The problem is that many, if not most, people who hear fibromyalgia assume the person IS just a malingerer. I heard a boss say once that an employee diagnosed with it needed to go to a country where you have to really scrabble to get enough to eat and stay alive, then she'd suddenly have to get off her lazy butt and forget this pretend fibromyalgia.
4
Please, please, please stop including ADHD in these kinds of discussions. The reason it is diagnosed more these days is we understand it better. If you have ADHD, or your child has ADHD, you KNOW it is not just a matter of paying better attention or being more conscientious. THose of us who medicate ourselves or our children for ADHD have made a very hard choice. It's not just a matter of "popping a pill" because you don't want to make "lifestyle changes." I wish everyone who had this attitude got to experience what it is like to have ADHD or have a close family member who has ADHD.
58
@Matilda Funny, when I got foster kids who had the diagnosis, most responded to routine and a lot of physical exercise before, during and after school. Suddenly the pills were no longer necessary. I agree that it is a legit diagnosis, but far, far too many foster kids are given the diagnosis because they won't "sit still and listen." I've also known of two cases where the mother taught her kids to act like they were ADHD, so they could get SSI---which she proceeded to live off of.
18
@Matilda
You are incorrect. You child may suffer from ADHD, but numerous children who do not have ADHD are being given diagnoses of ADHD. The New York Times has addressed this, including an article that was published several years ago, which stated that the diagnoses of ADHD had more than doubled within the past seven years. It is highly implausible that the number of children in this country who suffer from ADHD has doubled within 7 years. Doctors did not become more adept at diagnosing ADHD within seven years such that they were able to diagnose twice as many children as they had seven years earlier .
Parents are seeking ADHD diagnoses in order to gain an edge for their children over other children . Along with an ADHD diagnosis comes increase time to take exams. and other advantages which increase the chances that their children will gain admission to competitive colleges.
8
@Matilda Kids who need more exercise and fresh air are being put on drugs increasingly. Not all of course, but it seems to have become the easy go to. The increase in recreational drug dependence among kids who start early on drugs is sad.
6