A conference in Quebec gave me an excuse to escape to our northern border and French Canada for a little summer break. (Part 2 of “Pain” is in the hopper, and we’ll have it for you in October or November issue.) It was the fifth year for “Preventing Overdiagnosis: Winding Back the Harms of Too Much Medicine,” an annual convening of clinicians, academic types, health policy experts, medical journal editors, medical students and the concerned public, launched at Dartmouth College in 2013 following a series of provocative articles in the British Medical Journal.
Conditions often overdiagnosed, according to the initial report, include chronic obstructive pulmonary disease (COPD), bone fragility, aortic aneurysm, mammography, mild hypertension, pre-diabetes, gestational diabetes, low mood, Attention Deficit Hyperactivity Disorder (ADHD), predementia, thyroid cancer, chronic kidney disease, pulmonary embolism and polycystic ovary syndrome (PCOS). More recently the BMJ campaigners have been joined by non other than The Lancet, Journal of the American Medical Association (JAMA) and the National Cancer Institute, which in 2014 labeled cancer overdiagnosis “a major public health concern.”
Overdiagnosis, for the record, is defined as “diagnostic labeling of abnormalities or symptoms that are indolent, non-progressive or regressive, and that if left untreated will not cause considerable distress or shorten the person’s life.”
To this day I'm haunted by the memory of a young woman who came to see me at the school clinic after being given a diagnosis of DCIS: ductal carcinoma in situ. Not only was she convinced she had breast cancer (and was scheduled to begin chemotherapy), but because she had also been warned the chemo could damage her ovaries she was rushing to harvest as many eggs as she could to freeze them for the future.
Talk about your medical nightmare. Little did she (or I) know at the time, the National Cancer Institute had that very year launched a working group on cancer overdiagnosis, and was preparing to publish its recommendations. Chief among them? That “premalignant conditions such as DCIS” needed to be renamed to remove any reference to cancer, “just as many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should be classified not as cancerous or even pre-cancerous but as IDLE: indolent lesions of epithelial origin.”
As a result of the prevailing 19th century views of cancer, one prominent oncologist noted, some 50,000 women in the U.S. each year are wrongly diagnosed as having cancer – and treated for it, 20,000 of whom undergo mastectomy, increasingly bilateral. I can only imagine the psychological distress and collateral illnesses that ensue.
The overdiagnosis folks, likely because they have their hands full already, don’t really get into the tsunami of inappropriate surgical procedures sweeping the land – the total hip, total knee replacements, the hysterectomies, the Cesarians, the cholecystectomies – and the harm they cause. It’s not only the squandered resources and recovery time, but many of these -ectomies leave the -ectomized (or in the case of a C-section, the microbiome and therefore immune system of the neonate who eventually grows to become a toddler, a teenager, an adult) with lifelong limitations that aren’t completely explained or understood a priori.
They do, however, directly address the phenomenon (that in my experience is driven by Big Pharma and the guidelines writers on their payrolls, although this may be improving slightly) of what I like to call disease definition creep. How “when to treat” thresholds for certain blood markers (think cholesterol, glucose, creatinine to name just the most common) have all conveniently crept in the direction that would put more customers in the drug companies’ pockets. No surprise here then when it was announced that a recent review of clinical practice guidelines in the U.S. found that for 10 of the 16 guidelines studied the definition of what constitutes disease had been expanded.
Heading home, I stopped by the Orthopedics and Rehabilitation clinic at the Syracuse University Medical Center (SUMC) to check in on an illustrious Columbus native, I call him Dominic, who set up shop in upstate New York shortly after finishing acupuncture school. At the urging of one of the surgeons there, Dominic started working alongside the physical therapists to see if his particular brand of sports acupuncture might help get patients’ “stuck” muscles firing again and to speed resolution of pain.
Surgery candidates are basically given an ultimatum: eight sessions of physical therapy and eight sessions of acupuncture before elective surgery will be considered – and they can choose which to do first, although increasingly the two are done in parallel. Perhaps not surprisingly, many folks opt for the acupuncture first, dreading I suppose the image of a military type boot camp that awaits them.
Success, as it happens, breeds its own problems: two years in, word of Dominic’s impressive results have spread so that there’s now a three-month wait list to get in, and SUMC is looking to add two more acupuncturists over the next 12 months. Our first patient on the morning I was there turned out to be the recently retired chief of surgery. He’d gotten wind of what was going on downstairs, and apparently it’s the best thing he’s found so far for his plantar fasciitis.
Insurance reimbursement, presumably because it’s submitted under a physician’s order, also seems to work in favor of not just the patients but also the hospital, billing anywhere from $120-240 a session with most patients paying absolutely nothing out of pocket. Familiar complaints I saw respond reliably and surprisingly quickly to acupuncture alone or a combination of acupuncture and PT included: facet joint pathologies, bulging discs, spinal stenosis, spondylolisthesis, functional leg length discrepancies, weak glutes, shoulder, hip and low back pain, tennis elbow and, yes, plantar fasciitis.
Returning back to Columbus I immediately set out to survey the pain and orthopedic rehab landscape (the likes of Orthopedic One, NovaCare, Ortho Neuro, even OSU Sports Medicine) to see if anything like this is going on here in Columbus--and if not, why not. Physical therapists and orthopedists, feel free to reach out to me.
After 20 years in clinical research and patient education at St. Vincent’s Hospital & Medical Center in New York, Michael Barr became certified as an acupuncturist and Chinese medicine herbalist. He recently returned to his native Ohio and has an office at the Center for Alternative Medicine in Columbus. He can be reached at evacupuncturist@gmail.com
