Health-conscious Americans are constantly urged to be vigilant about going in for screening for diseases ranging from prostate cancer to depression to osteoporosis. How helpful is this type of screening? Our guest argues that not all screening should be considered prevention, and suggests that some of this screening is making us sick.
Guest: H. Gilbert Welch, MD, MPH, is Professor of Medicine and Community and Family Medicine and Co-director of the VA Outcomes Group at the Dartmouth Institute for Health Policy and Clinical Practice.
Dr. Welch is the author of Should I Be Tested for Cancer?: Maybe Not and Here’s Why, and Overdiagnosed: Making People Sick in the Pursuit of Health ( with Dr. Lisa Schwartz and Dr. Steven Woloshin).
The podcast of this program will be available the Monday after the broadcast date. Podcasts can be downloaded for free for six weeks after the date of broadcast. After that time has passed, digital downloads are available for $2.99. CDs may be purchased at any time after broadcast for $9.99.

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  1. PWH
    Reply

    Interesting segment and an interesting chapter in the book Overdiagnosed: Making People Sick in the Pursuit of Health on PSA and prostate cancer. I have recently had my PSA numbers rise since 2002 when my PSA was first measured. What this may or may not mean is the perplexing component of this particular disease and the indirect measure of it via PSA.
    By nature I am an odds player and the odds that I have prostate cancer are relatively high simply because of my age – 59. The odds that I have an aggressive form that will kill me in 3 years like Zappa and Fogelberg is low. I have no family history, a normal DRE (twice in the last week!) and no symptoms. In some ways I am sorry that I have even had a PSA at any time.
    So, I am in a conundrum in that I don’t want to be ether over-diagnosed and treated to my potential harm – proper functioning and economic. At this point while a biopsy has been recommended I am not sure that I will have that done. If its negative for PC — great, but the odds are against that. If its positive there is no way to know if it will advance aggressively or stay put — “like a turtle in a box”.
    Kind of no-mans land out here in the real world. Who to believe — Drs. Ablin or Welch or my trusted urologist, Dr. Murphy.
    Thanks for the show which provided me with more information to make not the right choice but an informed one.

  2. lcf
    Reply

    Didn’t hear the show; just read the comments. In 2006, I went for my “annoying” mammogram. God bless the radiologist who found the cancer cell (smaller than a grain of salt) in its early stages of development. I am alive today because of preventative screening. Enough said.

  3. RKM, MD
    Reply

    This was a very timely article. The April 20, 2011 issue of the Journal of the American Medical Association (JAMA) had a similar article with similar conclusions to those of Dr. Welch’s.
    And of course there have been a number of articles in the recent literature questioning the value of mammography and PSA for prostate cancer.
    It is impressive the quality of commentators that you have on your show, as well as your selection of news items and your intelligent evaluation of alternative remedies.

  4. Bill
    Reply

    I found this show interesting, but I do not support the notion that screenings and annual physical exams do more harm than good. It really depends on what actions patients take based upon the results of those tests.
    For me, I would rather know that I have cancer, even if it is in an extremely early stage, and may not ever pose a real threat to me. Since I would insist on a second series of tests, and multiple opinions as to the treatment that I should pursue, there is little risk that I would suffer needless side effects from an unnecessary treatment.
    Others may react differently, which is why the pros and cons of screening should be explained to all patients. Then they, in partnership with their physicians, can decide upon the best course of action.

  5. LB
    Reply

    thanks for the excellent broadcast

  6. frab
    Reply

    Very helpful as I head off to a bone density and mammogram (br ca on both sides of my fam) this week. As with another writer… I tried to vote 5* but was told I had already voted. thanks

  7. Rx
    Reply

    “…least [sic] they share in his tragic fate.” Huh?? Wake up.
    We are ALL going to share in this tragic fate. We are all going to die. But we should have the right to choose how we want to live and die and what treatments we want or DON’T want. Treatments should not be FORCED on us.

  8. B.V.
    Reply

    The side effects of selling & reading the book is not further illness or death; like it
    Is for certain drugs. Mr.M.S.there is no such thing as miracles or for that matter miracle drugs.
    If one follows true preventetative medicine; which is eating well,proper exercise, not drinking any alcohol or smoking; reacting properly to stress & not being exposed to enviormentsl hazards, one does not require drugs.
    Now this form of preventative medicine has never been practiced in the U.S. Becuase it can’t be patented or sold at an unusually high profit margin.The only true advancements have come in “trauma medicine” which is not needed very often. I would deduce by your writings that you are a very uninformed individual or that you have a financial interest in medicine; maybe you’re a Dr., or a hospital administrator; or a medical device sales rep or you fall for the medical establishment’s sales pitch…hook, line, & sinker.
    Thanks .

  9. John
    Reply

    I am currently a FNP Student nearing graduation. I listen to your program at least every other Saturday on my way to work. As I was listening to this program I was somewhat taken aback by this particular take on very well understood mechanisms for medicine and screening. Many of the screening processes don’t rely on just one item for concluding there is a problem. And the guidelines have been developed over a great deal of time and are based on very well run double blind studies that have been conducted by such entities as WHO, NIH, Harvard university etc… I think this program was INCREDIBLY misleading and the statements made were vastly oversimplified.

  10. Charles B MD PhD
    Reply

    The program presented a nihilistic and cynical view of “Prevention”. There was trite mention of efficacious interventions related to “diet” and “exercise” as being part of “Prevention”. In primary care there is certainly the opportunity for the care team to practice “Clinical Prevention” that has positive cost-effective outcome connotations.
    There should also have been an emphasis on “Self (Family)-care Prevention” that facilitates an awareness by the layman of factors that affect the probability of onset, progression and recovery from disease, that, in turn, facilitates the self-application of brief interventions for cost-effective care.
    (The following segment related to factors was cited above for “Clinical Prevention” by the Care Team. They could also be cited as relevant to “Community-based Prevention” facilitated by trained Community Health Workers)
    Factors that affect Onset, Progression and Recovery (of) from disease:
    Onset of Disease
    Risk Factor, if present, increases the probability of onset of disease.
    Protective Factor, if present, decreases the probability of onset of disease.
    Progression of Disease
    Stress Factor, if present, increases the probability of onset of disease.
    Resistance Factor, if present, decreases the probability of onset of disease.
    Recovery from Advanced Disease
    Antagonistic Factor – could include Complications of Disease – if present, decreases the probability of recovery (or “bounce back”) from disease.
    Resilience Factory – also known as “Resiliency” that should be distinguished from “Resistance” – if present, increases the probability of “Bounce Back” from advanced disease.
    One thing that could facilitate “Clinical Prevention”, “Community-based Prevention”, “Self-care Prevention” and “Family-focused Prevention” is a prioritization of education starting at least with, ninth grade Biology of “Public Health Biology” instruction about key concepts (eg, insulin function / resistance, endothelial function / dysfunction, bioenergetics / anergy, prefrontal cortex control of the amydala / emotional and violent outbursts, biological relationships / exploitation, immune system response / inflammatory response / vaccination, opportunity costs / environmental effects on health / pollution / poor water quality / hand & droplet transmission of infection, behavior / disordered behavior / first onset of psychosis, behavioral determinants of health / reading to the young / motivational discussions / meal timing & content / addiction / safe & unsafe sex, circadian rhythm / melatonin / healthy & unhealthy sleep / systolic dip / absent systolic dip especially in African American and Hispanic men / am systolic surge and stroke risk / diurnal timing of medication administration / self monitoring of blood pressure, self educational principles / organic learning / missed educational opportunities / integration of science (eg, the physics of football), reading & math & language (especially including Medical Spanish & Medical Portuguese) & physical education (and the Scientific study of Sport) & art (and art therapy) & drama (and case-based reasoning) & design (and animation of self / patient education) training, Systems & Health System Science education / lack of a Health Care System in only one advanced country in the world, the advantages of a Systems approach to facilitating health care outcomes that decrease the deficit, increase gainful employment and provide incentives for self, family and community care.
    The goal of the K-12 Public Education System should be in the education of ALL students in the above concepts very pertinent to “Prevention” AND the certification as Medical Assistants or Community Health Workers of a percentage of students equal to or greater than the percentage of the GNP consumed by health care.

  11. Heather
    Reply

    Just a come-on to buy more stuff. How disheartening. Isn’t it enough that you get a radio audience?
    Many people listening to your radio shows are OLD – what on earth IS a PODCAST???

  12. M. S.
    Reply

    Hey Joe and Terri–so Dr. Welch criticizes the “cynical”, rapacious motives of the hospital that offered the free PSA screening one Saturday so that it could then bill for several resulting tests and procedures, what Dr. Welch called a “lost leader”. Well, how is that different from what he’s doing on your show? He comes on, maybe for free, so he can take his shots at Pharma, screening, hospitals, etc. for the purpose of hawking his book to your large, devoted audience so he can profit from increased sales–are his motives “cynical” as well?
    And by the way–God Bless “Pharma”, whose astounding research and development has given the entire world drugs that are nothing short of miraculous, and have not only extended the life span but greatly improved the life quality of countless millions–including yourselves, I believe–with a vast variety of often life threatening conditions.
    We have hospitals staffed by devoted, dedicated professionals, who have to constantly “cover their asses” from exorbitant malpractice suits, providing a level of care and procedures that even 20 years ago would have been the stuff of science fiction: microscopic brain surgery, heart valve replacement, organ transplants, pacemakers etc. that save lives of the otherwise doomed and spare the grief and suffering of their family and friends.
    It is SOOOO easy to sit back and criticize, focus on the anomalies, nit pic the missteps, but the big picture is that we have the greatest medical system in the history of the world because of Big Med and Big Pharma and screenings are LIFE SAVERS. By the way, Big Med wouldn’t have to give so many unnecessary tests if they didn’t have to protect themselves from the claws of Big Legal–(hence the need for liability caps and tort reform).
    By the way, the likes of Frank Zappa, Dennis Hopper, and Dan Fogelbeg, all of whom died of prostrate cancer, would strongly disagree with the doctor’s premise. Dan had strong statements urging his fans to get regular screening and not to wait and see, least they share in his tragic fate.

  13. BJL
    Reply

    Thanks. always my favorite topic. Why can’t people understand the doctors DO NOT OWN your body and can’t TELL you what you have to do. They should tell you what you CAN do (as my doctor does). Otherwise find another doctor. I refuse to take medicine (have tests) without knowing what risks could be with or without. But most of my friends blindly do whatever their doctor says. Unless it is something they have to give up and don’t want to or exercising. The question becomes “who IS responsible?”
    R Lynch above should have found another doctor.

  14. Gebhard Steuer, MD
    Reply

    Thank you very much for this unmasking of the overselling of prevention. The infiltration of medical opinions with Pharma interest is pervasive and mirrored by the 1:10 ratio in my exam rooms: 1 drug rep for every 10 patients.
    I will get “Overdiagnosed”, place it my waiting room, make the MP3 version of your program available to my partners and annother $50 donation to Public Radio. Well done!

  15. Rose
    Reply

    This was a great radio show this morning. I generally listen to you all on my Saturday morning walks. And have been for years. I’ve felt this way about our medical establishment, for years, and I must buy this book and read it, wish all our doctors would do the same.

  16. Charles B MD PhD
    Reply

    What was admitted in the show was the “redefinition of prevention” that was specified without definition. Here is my definition of “clinical prevention”, an entity I feel qualified to define as a primary care physician.
    1) Clinical Prevention = a form of prevention that can be combined with clinical care by the primary care team and done during the course of a primary care clinic visit with the goal of identifying and acting upon factors that have a high probability of affecting onset, progression and recovery from disease.
    2) Key Clinical Prevention factors are:
    Onset of Disease
    Risk Factor, if present, increases the probability of onset of disease
    Protective Factor, if present, decreases the probability of onset of disease
    Progression of Disease
    Stress Factor, if present, increases the probability of progression of disease
    Resistance Factor, if present, decreases the probability of progression of disease
    Recovery from Advanced Disease
    Antagonistic Factor, if present, decreases the probability of recovery (or “bounce back”) from advanced disease
    Resilience Factor, if present, increases the probability of recovery from advanced disease.
    With the above view of clinical prevention it is possible for the primary care team to emphasize “positive factors” such as Protective Factors, Resistance Factors and Resilience Factors.
    So, the primary care team, in a positive way, can emphasize Aerobic Exercise as a Protective Factor, Resistance Factor and Bounce Back facilitator.
    Likewise the primary care team can emphasize QHS (bedtime) dosing of low dose ACE inhibitor medications (preferably ramipril) as “Protective” against stroke, heart attack, diabetes onset and diabetes complication onset, as facilitors of the patient’s “Resistance” against progression of proteinuria and facilitative of “bounce back” from marked proteinuria (“kidney problems”), especially in African American & Hispanic men.
    I am sure that Dr. Welch, as an expert in Men’s Health, can inform us of why QHS ACE inhibitors are especially important in African American and Hispanic men.

  17. J. Merritt
    Reply

    Also, one of the basic problems now, is that even though these very expensive screening and treatment programs have produced very little benefit, they have become the standard of care; meaning that any physician that does not comply opens themselves up to potential litigation. People have forgotten that the goal of medicine is quality life years, and that by treating numbers and following guidelines produced by committees dominated by people beholden to special interests, patients often loose more quality life years than they gain.

  18. J. Merritt
    Reply

    Thank you for this show. my husband is a doctor and he has been saying this for years. In a two year program at UNC Medical School with Dr. Steve Kaiser, he learned how to interpret study data and how to apply it to actual practice. As he has watched medicine become dominated by corporations, the profit motive has placed tremendous momentum behind such things as testing, screening and treatment of elevated cholesterol and blood pressure. He has watched his colleagues forget the basics of teaching healthy lifestyle and diet to their patients, for which no corporation can make a profit.

  19. durhamsmith
    Reply

    I’m not sure that the vote I made for the show worked properly. Before the vote the score was 4.5/5 with 20 people voting. I clicked the last star and the score became 4.4/5 with 21 people voting. I meant to rate the show as a 5 but I seem to have lowered the average! What happened?
    durhamsmith@yahoo.com

  20. Rebecca
    Reply

    Thanks again for a great radio broadcast- this one with with Dr. Welch on Overdiagnosis.
    My primary comment is that as a mental health care provider for about 30 years my #1 observation is that when Managed Care came into the field of health care treatment in about 1986-87 medicine began a notable decline from a focus on the wellness and care of folks to a money making business/industry. Doctors, nurses, social workers, psychologists. physician’s assistants, nurse practitioners, counselors, etc. have done what they can to keep serving people (and they mostly do care) but it is most difficult to work for less money just so the medical management folks organize the system to make a their chunk.
    Anyone can see it when the pharmaceutical and insurance industries are making motions to frighten the general public and yes their providers into using and even overusing their products purely for the profit of the companies/health care industry.
    Perhaps a few people in our population have benefitted from early diagnosis yet most certainly many have been harmed by too early & over-diagnosis. Hey, but then there is no oath or even code of ethics in business.

  21. ms
    Reply

    Just paid over $3500 out of pocket (over $10,000 including what insurance paid and write offs) to find out the tiny spot on my breast was not cancerous.
    I have no family history at all of breast cancer. No symptoms at all. Spot turned out to be necrotic tissue left by a hard fall a couple of years ago.
    We are so programmed to react to the possibility of cancer and early detection that we go to extreme measures when confronted with the flimsiest of evidence.
    When I went for a sonogram the tech said that the did lots of them on breasts because doctors in region look into everything suspicious very aggressively. The surgeon told me that they have a special room at the hospital for doing the stereotactic bioposy. And I thought “Yeah, and now they have to pay for it…I don’t think questioning the profit motive of hosptials and drs is cynical. I think it is appropriate.

  22. durhamsmith
    Reply

    VERY helpful and informative; intend to buy the book and read in detail; makes lots of sense; as logical as Cris Crowley and Harry Lodge who wrote Younger Next Year.

  23. WhiteDove
    Reply

    Thank you. Now i have numbers to take into my doctor. I agree that doctors are screening and treating people who don’t really need it. This makes more people feel that they are sick and causes more dis-ease in the population. It also causes people or the government (all of us) to spend more. I will definitely suggest this book to my doctor.

  24. Sathya Jyothinagaram
    Reply

    Enjoyed the show. Mostly on the spot. However please correct an error in Dr Welch comment. The T score level to diagnose osteoporosis is still less than -2.5. It was not changed “…to less than -2.0 as stated by Dr Welch”
    Sathya G Jyothinagaram, MD, MRCP (UK), FACE
    Division of Endocrinology, Charlotte Medical Clinic
    Charlotte, NC 28203
    Clinical Associate Professor, Dept. of Medicine
    Univ. of North Carolina, Chapel Hill

  25. Lisa Merritt, M.D.
    Reply

    Always enjoy your informative program, today’s session included. My concern is there still needs to be focused attention in certain populations to address the glaring health disparities that exist among different racial and ethnic groups. For example, we still lack sufficient screening and aggressive management of African American patients for diabetes, hypertension, AIDS and cancer.
    This patient population suffers disproportionate rates of morbidity and mortality from complications of these disorders including, visual impairment,chronic pain, kidney failure, amputations and shortened lives. Clearly prevention of such complications is well worth the screening and early intervention to avoid later tragedy. I hope emphasis can still be made on individual assessment and prioritization of patients to optimally manage their care.

  26. K. K Kelleher
    Reply

    These criticisms of the changing targets of prevention, are easy. However, doesn’t Dr. Welch rely on the expertise of national recognized and presumable unbiased panels, such as NCEP, JNC7, and US preventative Services? Who should physican rely on?

  27. R Lynch
    Reply

    Fascinating show – thanks! One of the problems I’ve experienced with doctors is that when I try to refuse a test, the doctor gets mad and then withholds other treatment. I am on blood pressure medication – maybe unnecessary according to this show ;-) and I was unemployed for a year and a half with no health insurance. My doctor didn’t understand that with no salary and a mortgage and bills, I couldn’t pay upwards of $400 out-of-pocket for labs, and she refused to give me a prescription for my blood pressure medication. What does one do in a situation like that? Do doctors in our society have too much power?

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