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From the Townsend Letter
August/September 2015

Book Review
A Doctor Debunks Assumptions About Medicine
review by Ira L. Goodman, MD, FACS, ABIHM, FAARM
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Less Medicine, More Health:
7 Assumptions That Drive Too Much Medical Care

by H. Gilbert Welch, MD, MPH
Beacon Press, © 2015; hardcover; 240 pp.

Gilbert Welch is an epidemiologist from Dartmouth who has published widely on the overuse of conventional medicine. His two previous books, Should I Be Tested for Cancer? in 2006 and Overdiagnosed in 2012, were in the same genre, were well referenced, and espoused a rational argument against the predominant sentiment that early diagnosis is always preferable. His latest book is more lay friendly but offers a great deal to the physician audience. He lays out the 7 assumptions that drive too much medical care and debunks each one. These are: (1) all risks can be lowered; (2) it's always better to fix the problem; (3) sooner is always better; (4) it never hurts to get more information, (5) action is always better than inaction; (6) newer is always better; and (7) it's all about avoiding death. The current book is more about therapy as opposed to diagnosis and screening, although the threads of his philosophy and prior books (which are both excellent) are clearly evident throughout. I found his casual style and anecdotes very entertaining. He distinguishes among data, information, knowledge, and wisdom. It's easy to collect data but hard to produce useful information, and even harder to know what to do with all of it. Too many data can cause much more harm in the form of anxiety, unnecessary follow-up testing, and coerced invasive treatments; and sometimes morbidity or mortality is the result.  Our fee-for-service paradigm, aggressive "community standards," and, quite frankly, greed all can conspire against the well-being of a patient.
I loved Welch's metaphors and stories throughout the book. One involves the "barnyard" of cancer types that he calls birds, rabbits, and turtles. The birds are the aggressive cancers that fly out of the barn way before any screening or diagnosis is applied. They metastasize early, so early diagnosis is not helpful. The turtles, on the other hand, are extremely slow growing cancers that are never destined to be clinically significant anyway and when discovered can lead to mutilating treatments when the patient is frightened into action. Prostate cancer is of course the poster child for turtles. Screening for turtles does more harm than good. The rabbits are the cancers that if detected early can be controlled to the benefit of the patient. The problem, of course, is that there are many more turtles diagnosed and treated than birds or rabbits. Therefore there is an epidemic of diagnosis, screening initiatives, and treatment modalities that is completely out of control. We all know normal people who have been transformed into "survivors" who are consumed with anxiety for the rest of their lives after having been diagnosed and treated for diseases that probably would never have affected them clinically in their lives.
I found the book well written, enjoyable to read, and convincing. I highly recommend, however, reading all Welch's books in the order that they were published to benefit from all of his research and insights.

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