Are Patients Being Over-Diagnosed?

August 2, 2011 by Anne DiGeorge

When a patient goes to a doctor with an ailment, they expect a diagnosis and treatment, and preferably a prescription for medication. Many patients feel if they do not walk out the door with a prescription in their hand or have one called in to their pharmacy, that the doctor has not done his job.

Because the patient's expectations are high, on one hand doctors feel pressured to oblige, and on the other hand, they are being accused of over-diagnosing patients. Some doctors err on the side of caution, just to be safe, and will write the much coveted prescription.

Sometimes there's no diagnosis that can be made during the visit because a patient's symptoms point to any number of diseases or ailments. Most physicians might want to wait until they study all the test results.

In an era when doctors are sued for malpractice for almost anything, some doctors cover themselves by ordering a medication that will do the least amount of harm while they wait for test results or while they consider other medical options before making a diagnosis.

For many patients, it is a "wait and see" game -- waiting for more time to pass, or for more symptoms to manifest before a name is put to their ailments.

Once a patient has a name for their disease - preferably a disease they can look up on the internet - they will leave the doctor's office much more at ease than they were when they arrived.

We want to know what is wrong with us, and we want a name to go with it.

A patient who hears "I don't know what is wrong with you," can translate that to mean "He thinks I'm crazy." The patient who leaves the doctor's office with a prescription can still be in "some" pain, but the mental knowledge that a prescription will possibly help that pain, makes them leave with a more positive attitude, sometimes with "less" pain symptoms.

Sometimes a patient "knows" what is wrong with them and treats the primary care physician's office like a drive through window, picking up their referral on their way to the next doctor's appointment.

Some physicians are swift to oblige and don't mind handing out referrals. Others give a thorough exam and painstakingly document their notes in the patient's chart.

Patients who self-diagnose by asking for referrals without the benefit of indepth consultation or physical examination by their primary doctor run the risk of being mis-diagnosed.

Bringing a laundry list of symptoms to a visit often swamps the physician with too many options so that he feels like he has to order a medication to cover interim time - the time between the tests, the date of the results and execution of the treatment plan. This may be an antibiotic, a low dose steroid, a pain medication or a placebo.

While patients are very quick to blame doctors for over-diagnosing, they have to accept part of the blame when they demand instant cures for their symptoms.

For most people, the internet has become their first pit stop when they are researching their symptoms. The patient can get hundreds of instant results with an endless sea of links to click on, some of which may even contradict one another.

The internet can give you basic information regarding treatments, procedures, new medications, and even some pointers on how to choose your physician, hospital and insurance plans.

But the internet should never replace your "real" doctor.

Unless there are medical credentials after someone's name (MD, PhD, etc), much of the information found on medical websites is written by lay people, government agencies, and special interest groups.

Just like on HubPages, many authors of medical articles are not medical professionals. They are writers supplying content about a particular medical subject, of which they either have personal experience or they have researched it. Then they compile the pertinent facts into an article and publish it on a website.

Where did they get their information?

From the internet.

Are you interested in writing for a medical website?

Many websites allow laypeople to "upload and edit" any type of content to their websites, not just medical content; for example, Parkinson's Foundation, About.com, WikiDoc, most of the Wiki websites, Nature Medicine, Everyday Health, The Lancet, Yahoo Health, MedPage Today, and e-how, just to name a few. These links will lead you to the "guidelines for writers" on each website.

Writing content for medical websites can be quite lucrative. As previously stated, you don't have to be a medical professional; you just have to write like one and follow their guidelines.

In many cases, internet articles, reviews, testimonials, and non-scientific information are out-of-date. Look at the website address bar while you are on some of these medical sites. Sometimes they show the document date within the URL address. In other instances, there might be a date of creation at the end of an article. You should always be aware of the age of the article.

Standard disease and disorder information on websites like WebMD does not change from year to year. Articles are often three or more years behind today's date, with the exception of their "news" sections.

Some websites, in an effort to appear knowledgeable and authoritative, cram tons of links on their articles so that while you are reading, you are bombarded with alot of information. It is hard not to click on links before you finish reading the article.

When links take you to websites other than the one you were reading on, it is the rare reader who finds their way back to finish reading the original article. Websites that over-saturate the reader with links once you follow one link, you find yourself clicking another and another, so that before you know it, you are so far afield that you never get back to the original article to finish reading.

Bottom Line: You should never stop researching for more up-to-date information. Don't take any one website's information as gospel, no matter how reputable they are.

Then make an appointment with your physician.

Some websites have quizzes which are meant to be a cursory pre-screening effort, similar to a community hospital's "screening day" where people go for peace of mind, or to "see if" they have disease markers.

In the last ten years (per accompanying video), it is the general consensus of medical professionals that they are seeing more cancers in certain age brackets because they are screening for them within those age brackets. What about all the ages that aren't screened? Does the incidence of disease hold true for them?

Once a disease, a disorder or a patient's belief is noted in a patient's medical record, it is very hard to get it removed. Although it isn't supposed to, the information influences each doctor who has the patient under their care.

It can even hinder an application for life insurance or when changing plans for medical insurance (for example: going from a company based group plan to a non-group medical insurance).

I don't know how many times I've read in a chart that a patient is suspected of having "blank, blank disease." Every doctor who reads that patient's notes will be influenced by what he read. No matter what treatment or tests are conducted, the notes in the chart will always be in the back of their mind and possibly influence how he interprets (or misinterprets) test results.

• "The patient has a history of bipolar disorder."
• "Oh yes, now I remember. I read in his chart that he exhibits some paranoia due to ....."
• "Patient wants referrals to many specialists to rule out ____ disease."
• "The patient believes she has breast cancer but her labs do not show markers and her imaging studies are normal."

When a doctor notes his speculation or reasons for his tentative treatment on a chart (true or false), it can be a death sentence for the patient.

Barbara, age 33. Unmarried, no children. In relatively good health, she does have a history of breast cancer on both sides of her family. Parents are both deceased; no siblings. No health insurance, no primary physician.

May 1999. Barbara found a lump in her left breast. An exam at the free clinic suggested the cyst may be fatty tissue possibly due to her 30 pound weight gain. She somewhat agreed with the doctor's diagnosis because some days when she felt around for it, it wasn't there; other days it felt like a baseball. A mammogram was not ordered since her age was under 40, the recommended age for mammography.

January 2000. Barbara met a different doctor at her free clinic appointment this time who considered the lump suspicious. Yes, he definitely felt a lump, he told her. He ordered a medically necessary mammogram and Barbara made the imaging appointment for the next day at the free clinic. Seven months had gone by since she first felt her lump. Barbara convinced herself she was on the road to breast cancer.

After the mammogram, she had to wait for the clinic doctor to call her with the results. Two weeks went by and he never returned her calls. By now, she was a basket case. She remembered the mammography technician telling her that doctors did not routinely call patients with test results unless the test showed an abnormality. Barbara reluctantly conceded that to be the case.

In March 2000, she started a full time job. On May 1, 2000 she became eligible to participate in the company's group HMO health plan. She found a local doctor who took her new health plan, but couldn't get a "new patient" appointment until June 15, 2000.

She knew her HMO insurance required a referral from a primary doctor to go to a surgeon for a consult. A week after making the appointment, she was beside herself with worry and called the office to ask for an earlier appointment.

As soon as the doctor entered the exam room, she blurted out that she didn't want to waste his time, she was just there to get a referral to a surgeon to treat her breast lump. She was pretty sure she had breast cancer, she just needed an appointment with a surgeon to take care of her right away.

He insisted on doing an exam anyway, stating he couldn't give a referral without documenting some patient history. The clinic faxed over her mammogram written report, which was now 6 months old. The study was unremarkable; he did not have access to the films. After an exam, he said he wanted to try to aspirate the cyst because he felt it was probably full of fluid.

Barbara agreed and 15 minutes later, the thin small needle held a few cc's of clear fluid. He said the lump could hardly be felt now after drawing out the fluid and most likely this was just a benign cyst and nothing to worry about. He said he would send the sample to the lab to be tested. To give her peace of mind, he would order an ultrasound of her breasts but first, her insurance had to approve the test.

In her chart he noted: "patient tolerated fine needle aspiration left lateral breast, producing 1 cc clear fluid and reduction of breast cyst. Pathology report requested. Patient expressed that she was pretty sure her breast lump was cancer. Follow up with bi-lateral breast ultrasound imaging, pending insurance approval, then re-evaluate."

Barbara's HMO would not approve the bi-lateral breast ultrasound, citing there was not enough medical necessity.

Three months later, Barbara's cyst was back and she was scared to death. She changed her primary doctor to another primary doctor. At her first appointment, she immediately asked for a referral to a surgeon. After consulting with the surgeon, she told him she not only had a fear of going through cancer treatments, but believed the surgery would reduce her risk of getting cancer.

Based on doctor's notes, patient mental status, family history and two recent mammograms, Barbara's insurance approved surgery for bi-lateral mastectomy.

Surgical summary: Lymph nodes and tissue pathology: no evidence of cancer cells.

She was a month shy of her 35 birthday.

Mental disorders and diseases are the most over-diagnosed conditions in medicine today.

Because free samples given by drug company representatives - the ones who go in to see the doctor before you, while you sit in the waiting room - new drugs are being pushed all the time, hoping physicians will prescribe them to their patients.

The incentive of free samples is a two-way street. Patients welcome free samples because of the high cost of medication and doctors agree to distribute them to their patients and give feedback to the drug company.

Bi-polar disorder (also known as manic depressive disorder or mania depressive disorder) is diagnosed more now in the 2000s than it ever was in past years.

Somehow, I think if the leap had been made to make this diagnosis sooner, people with this disorder would not have suffered so long. This is probably one medical area where over-diagnosis would have benefited with prescribed medications and treatment, as opposed to doing more harm by waiting so long to "put a name to it."

In children, ADHD is high up on the list of over-diagnosed conditions and with good reason, given their diets and in-your-face distractions of everyday life. Since the late 1980s, many parents have taken the initiative to look for underlying reasons why their children are hyperactive or have attention deficits. They are tweaking the diets of their children and opting for natural remedies instead of prescription medication, due to the long term implications of dependency and possible organ damage.

Autism never used to be diagnosed so readily. In fact, my son, who is 29 years old as of this writing (2011), was diagnosed as autistic when he was five years old. It took better than three years to get a diagnosis for him because doctors didn't want to "label" him. They were fine with labeling him as ADHD, which in fact he did not have. A diagnosis of Autism could take several years. Doctors didn't have a clear criteria in the 1980s, and so it not readily diagnosed at the time.

Doctors who did diagnose Autism were put under the microscope for how they arrived at that diagnosis. This meant providing lots of documentation not only to the medical community but also to the insurance companies who footed the enormous bills for testing and for services.

For my son, I had to do my own research and figure out what worked. There were very few books written on the subject. Through trial and error, I studied his diet and made changes as needed. I developed a sliding scale dosage to regulate his intake of oral vitamins and supplements to treat fluctuations that were detected by blood tests. I ultimately had to change his everyday environment (at home and school) to sift out the decibels of noise and "busy-ness" of his surroundings and put certain educational tools in place so he could continue to go to school with other children, such as: develop an IEP (Individual Education Plan) that was updated every six months, get the school to provide a one-on-one aide, a school vehicle to transport to and from school which was limited to 6 students, and creating a specialized schedule for school attendance.

Today he is a very high-functioning 29 year old, holds down a full time job, has a drivers license, bought his own 2010 car, manages his bank account and shops for his own food menu. He takes one medication for depression. For the most part he is regulated by diet, vitamins and supplements and redirection from behaviors, like cheating on diet with soda or wheat products. Today this involves 75% less redirection than 5 years ago and I suspect as he gets older, he will need less redirection.

When I remember back in 1989 that doctors wrote in his chart that he'd "never be high functioning", I wish they could see him now.

Never say never.

Many doctors say they don't over-diagnose; they make what is called an early diagnosis. Documenting an early diagnosis in a patient's chart is a "cover-my-ass" maneuver which is usually subject to change as more test results come in. Early diagnoses are educated guesses.

Sometimes when a physician suspects a certain disease or disorder early on, while waiting for final test results, he will order a prophylactic medication, which is a "just to be on the safe side" type of medication.

Sometimes it is an antibiotic. But sometimes it is a placebo medication - a sugar pill - when they are afraid the real medication may influence the outcome of certain tests. Remarkably, some patients will say they feel better while taking it and others will say it didn't do a thing for them.

Timing of Tests Per Insurance Guidelines

Our insurance companies hold all the cards when it comes to tests and studies. If a patient has a colonoscopy in 2010 and presents with symptoms where a doctor might want to conduct another colonoscopy in 2011, most insurance companies will not pay for the second one. The rule of thumb is a colonoscopy every 3 years or else the patient has to pay their own expenses.

Because of being outside the time guidelines, those patients will have to endure other tests to get a diagnosis, such as upper and lower GI performed in place of the colonoscopy.

Patients are at the mercy of healthcare insurance companies when it comes to the tests they need in order to get a diagnosis. Each individual insurance company decides what tests and procedures they will pay for, how often and how much they will pay, and how much the patient will pay.

Your Private Information and Insurance Companies

In the case of making an early diagnosis, many patients will pressure a doctor to perform certain tests to "rule out" or to "make sure" that they don't have the disease they suspected they had when they walked into the doctor's office. Other patients blame doctors for ordering tests with high copays they can't afford.

It is true that the schedule of fees are set by the insurance company along with the doctor and/or healthcare facility, and often they are set at a very high rate. That is because the insurance company will only pay them so much of a percentage. When a test has a high fee or copay, it doesn't mean the cost of the test increased. By raising the cost, the doctors and health care institutions will get more compensation. Ultimately it all lies in the hands of the insurance company which tests we are permitted to have, how much they will pay and what our cash outlay will be.

Who Reads Your Medical Information?

You should be very concerned about what a doctor writes in your chart and records. In fact, you should be downright scared.

Whatever a doctor writes in a patient's chart, whether it is an early diagnosis or a suspected diagnosis, you'd be surprised that it's not only your healthcare insurance provider who reads it.

That information includes the history provided by a patient stating if their ailment is due to a prior car accident, listing surgeries and physical or mental diseases, any tests they've had in the past even if it was when they had different insurance coverage or lived in a different state, and how long they have been exhibiting their symptoms.

They can also color the way a "future" medical care provider treats you - personally, medically, and professionally. Even prospective employers have a certain amount of leeway to access what is in your records before deciding to hire you. They do have to show justifiable means as to why they want to see it, but even though we may feel it is none of their business, today it has become so commonplace. Simply stated, there are so many hands in the pot, and we don't know who they are until we are asked to sign a release form so they can request the records and go look.

I know one gentlemen who signed consents for all his past doctors to send his records to his present doctor to keep his records all in one place. He and his wife bought a house and decided to get a life insurance policy so his wife would be able to pay off the house upon his death. When he applied for $250,000 life insurance, he was given a physical exam, then he was asked to sign a consent so they could access his medical records.

Ten days later he received a letter from the insurance company stating he was uninsurable because of the array of medical tests that were performed to "rule out" certain diseases and because his cholesterol was higher than they would like to see it. The only other options he was given was to pay higher premiums in order to get the life insurance coverage he wanted.

Screenings

We hear on the news all the time that early diagnosis via screenings has saved many lives.

Cancer researchers estimate that the number is closer to 1 in 5,000 than the "many lives" we are led to believe, as we see in the video accompanying this article.

With the high cost of medical care in the United States, many people believe that we are over-screened, over-treated and over-diagnosed.

Part of the blame rests with "screenings" and "preventative" medicine.The age ranges of screening have been changed to "look" for cancers in certain parts of the population who were not screened before.

• Does that means there is a higher incidence of the disease?
• Or, does that mean the disease was there all along or the decreased sensitivity levels of the screenings are now picking up on it?

Part of the blame rests with the ever changing guidelines skewed to meet the lowered criteria of diseases.

• Many more people fall within the guidelines of a disease, as measured by their test results.
• What we would have considered a mild case 10 to 15 years ago is now a definite disease.

An example: As of January 2011, just 8 months ago, Harvard Medical School lists the standard for a fasting blood sugar at 126 and over.

• That means if your blood glucose measured 126 or more, you are considered diabetic and you will be prescribed insulin to control your blood sugar, making you an "insulin-dependent diabetic." Clicking the Harvard link will show you the illustration.

Failure to take into consideration other blood levels like metabolic and lipids, now results in treating just diabetes, and not the whole picture. If the whole picture were taken into consideration, perhaps adjusting thyroid medication or cholesterol dosage would remedy the elevated blood sugar readings.

Steroids and statins use (cholesterol drugs) can also be the reason for a diabetic reading. It's a well known fact among medical professionals that statins taking to regulate cholesterol raises your blood sugar. Again, simply modifying those medications along with diet and lifestyle changes can put off being dependent on insulin for years, if ever.

So, do you think we are over-diagnosed in today's world? Your comments are welcome.

© 2011 Anne DiGeorge

3/16/2014 - Updated by Rachael O'Halloran with current links and replaced pixelated copyscape logo. 4/9/2017 -republished the hub after an extended hiatus