A Less Is More View of Medicine

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H. Gilbert Welch, MD

The truth is screening is a mixed bag. It makes more sense for some cancers than others and for some individuals than others. But it should always be an informed voice.

—H. Gilbert Welch, MD

Title: Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care
Author: H. Gilbert Welch, MD
Publisher: Beacon Press
Publication date: March 3, 2015
Price: $24.95; hardcover, 241 pages

He’s the best physician that knows the worthlessness of most medicines.

—Benjamin Franklin

Many think the biggest problem in medical care is that it costs too much or that health insurance is too expensive, too uneven, or too complicated. But according to nationally regarded health-care expert H. Gilbert Welch, MD, the central problem is that too much medical care delivers too little value.

Drawing on his 25 years of medical practice and research, Dr. Welch noted that while economics and onerous regulations and laws contribute to the excesses of American medicine, the problem is essentially created by our general public, who steadfastly clings to the notion that more medical tests and care are better care. Dr. Welch soundly debunks this mindset in his new book, Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care. Dr. Welch knows this territory well, as he is the author of two previous books: Should I Be Tested for Cancer? Maybe Not and Here’s Why and the highly acclaimed Overdiagnosed: Making People Sick in the Pursuit of Health. And he is a frequent guest contributor to national newspapers and television shows.

As expected, aside from an introduction and conclusion, the book is structured around Dr. Welch’s “7 Assumptions,” which makes for a modular, easy-to-follow format. Dr. Welch is Professor at Dartmouth Medical School but writes in the style of a trustworthy country doctor, urging readers to reject the temptation of trying to reduce all health risks by insisting on the latest technologies and tests. The informed health-care consumer must also be cautiously skeptical.

Challenging Common Assumptions

In “Assumption 1, All Risks Can Be Lowered,” he challenges its potential dangers with an example of preventive measures gone awry that readers of The ASCO Post will appreciate. After explaining the rudiments of the randomized clinical trial, Dr. Welch made his point, stating that the history of hormone therapy serves as “exhibit A.”

During the 1980s and 1990s, hundreds of studies linking hormone replacement to a lower risk of cardiovascular disease were published. “That’s what led Mom’s doctor—and thousands of others—to start millions of women on hormone replacement…. Soon after the new millennium, the results of follow-up studies were published, showing that hormone therapy on women like my mother caused as many problems as it solved. Millions of women like my mom were given the drug to prevent future problems…and that turned out to be a huge mistake.”

As we know, one major problem was that hormone replacement increased the risk of breast cancer, and following the publication of the follow-up trials, millions of women went off hormone replacement therapy. Dr. Welch writes, “You could see the effect from space: The rate of breast cancer dropped nationwide.” This isn’t a newsflash for the oncology community, but it’s good to revisit past mistakes, and Dr. Welch’s interesting use of anecdotes makes for an enriching read.

After a discussion about cardiovascular issues, in which Dr. Welch debated whether doctors should “manage the problem of angina or try to fix it,” he boiled it down to the underlying theme of much of the book: money. In this case, balloon angioplasties done by cardiologists are, in effect, taking advantage of our generous fee-for-service system. To make his point, he cited a trial that found “the patients who had their obstruction ‘fixed’ with balloon angioplasty were no less likely to die of or have a heart attack than patients who had their obstruction ‘managed’ with medications.”

Misconceptions About Cancer Screening

Most of Dr. Welch’s book is interesting and written in a way that’s accessible to the smart lay public. In several chapters, Dr. Welch challenges the readers’ assumptions about screening, specifically cancer screening, an area he is passionate about. “I know I sound like a broken record on this issue…. For a quarter of a century, cancer screening has been a central thrust of my research and writing for the public. Nevertheless, I know that a lot of misconceptions about cancer screening persist. Your intuition might be that cancer screening is a no-brainer…. In this chapter, I’m going to ask you to think again.” And he does, over and over again.

Although much of this material about the risks of false-positive results, overdiagnosis, and lead-time bias will be like watching reruns for the readers of The ASCO Post, it does provide a thorough overview of our current screening environment, warts and all. Will Dr. Welch’s take on this complicated issue clear the air of contentious debate? No, but it will add a well-reasoned voice. He ends the chapter, “The truth is screening is a mixed bag. It makes more sense for some cancers than others and for some individuals than others. But it should always be an informed voice.”

‘Strive to Live, Not Avoid Death’

The chapter “Assumption 7: It’s All About Avoiding Death” is perhaps the book’s strongest, giving the reader a prescription: strive to live, not avoid death. Here, in a compelling narrative, Dr. Welch shared his father’s struggle and ultimate death from colon cancer, which unfolded during Dr. Welch’s first year of medical school and “quickly turned into one of the hardest years of my life—and one of the most important.”

Even now, the oncology community struggles with imminent death and when to tell patients there are no more curative or life-extending options. It is one of the defining issues in the evolving practice of cancer care, and Dr. Welch offers sound and compassionate counseling. “Embrace life. And don’t dwell on death—recognize that it’s part of life.”

A Recommended Read

Once again, Dr. Welch has turned out a fine book on health care. He put more of himself on these pages than in his previous books. It’s always a gamble for an author to get personal with his readers in this type of book, but it was worth it, because readers will come away liking Dr. Welch.

This is a recommended read for the layperson and the professional health provider. Many of his messages and ideas should be carefully considered, as we endeavor to create a better health-care system. Incidentally, all the proceeds from his books go to charities. Another reason to like this author. ■