November 12th, 2018
In The New York Times this week, Dr. Dhruv Khullar, physician at New York-Presbyterian Hospital and professor of medicine at Weill Cornell, offers an insightful and nuanced examination of a modern phenomenon in health care — the increasing number of recognized diagnoses. As Khullar points out, being able to label conditions as diseases offers several benefits, but there are also down-sides:
“Our ever-expanding armamentarium of diagnoses no doubt offers comfort, attention and a path to treatment for many previously undiagnosed — and undiagnosable — patients. But we may also be medicalizing much of normal human behavior — labeling the healthy as diseased, and exposing them to undue risk of stigma, testing and treatment.”
Khullar’s piece brings up a difficult question: How do we distinguish between diagnoses that are helpful and ones that expose patients to harm? Many diagnoses help some patients and harm others, making this question even more complicated.
This question is tricky, but we can start to answer it by identifying key features of diagnoses that appear to cause more harm than good.
One of the potentially harmful consequences of medicalization is that “that medicalized diagnoses often come with medicalized treatments,” Khullar points out. New treatments can be positive of course, but when new disease terminology originates from the company that later sells the treatment, we need to be wary.
A classic example of drug companies creating a disease is the makers of Listerine inventing the term “halitosis” in 1921 to sell mouthwash. Now, drug companies go far beyond simply putting an ad in the paper selling a new disease. Companies spend an enormous amount of time and money raising awareness among the public and doctors about a new disease, including sponsoring key conferences, hiring experts as consultants, and funding continuing medical education classes about the disease.
As journalist Roy Moynihan wrote in his examination of the marketing of female sexual dysfunction in The BMJ, “The first step in promoting a blockbuster drug is to build the market by raising public awareness about the condition the drug is designed to target.” When we see ads for new diseases, we need to ask: “What organization has created and popularized this disease, and how close are they to the organizations that manufacture the treatment?”
In the article, Khullar tells the story of a patient who cried tears of relief after getting a diagnosis of fibromyalgia. In her case, having a name for the condition provided her with comfort and recognized the pain she had been dealing with for many months.
But what if you received a diagnosis for a condition without experiencing pain or other symptoms? This would more likely lead to anxiety and stress rather than relief. For example, some doctors have criticized the popularization of “prediabetes” as a diagnosis, because it creates unnecessary panic and can lead to harmful overmedication. Another one of my favorites is “malocclusion,” which simply means that one’s teeth are misaligned. Although not a disease, this scary-sounding diagnosis makes it seem as though braces are a medical necessity. In fact, there is little consensus in orthodontics about if or when braces are medically necessary.
There are also diseases which have a clearly defined patient population at first, but over time, the indications leading to diagnosis become muddier and the patient population expands greatly. Khullar points to childhood mental health disorders as a potentially harmful examples of this “indication creep,” citing the greatly increased number of children diagnosed with ADHD and child bipolar disorder.
Indication creep would not be a problem if we knew that everyone who received treatment was helped by the diagnosis. Unfortunately, for many people being diagnosed with conditions that expanded their indications, receiving a diagnosis may lead to harmful overmedication (such as overtreating hypertension in older adults) or no useful changes in care (such as women with mild PCOS) and can increase anxiety and stress for those diagnosed.
More newly recognized diagnoses is not inherently a good or bad thing. But we need to look deeper at this pattern – who is creating these diagnoses, who they are affecting, and how they are treated – to better understand how some diagnoses can be helpful and others harmful.