How many times have you heard the story of the patient that gets exploratory surgery only to have an unknown cancer spread rapidly right afterwards? While our healthcare system tries most often to "fix it," are there times when nothing should be done but to wait and see? A New York Times essay explores how we might look at health risks and decide to ignore some of them.

 

Healthy in a Falling Apart Sort of Way

 

By Jane E. Brody

March 2, 2015 5:45 am

 

When asked on a medical form to evaluate my overall health, I invariably check “healthy.” But I sometimes wonder how accurate that is.

After all, I do have arthritis that necessitated a double-knee replacement 10 years ago, and I find it increasingly difficult to open containers designed to thwart a 2-year-old. My spine is a mess, and my back hurts from time to time. I have tinnitus and some hearing loss in one ear. I was treated for breast cancer 16 years ago. I take a statin to lower a cholesterol level that defied conservative measures of diet and exercise. And I constantly have to practice remembering people’s names.

So, at nearly 74, how healthy am I? Well, I also walk three miles and swim three-quarters of a mile nearly every day. I’ve taken over most of the chores my late husband once did. I shovel and sweep my walk, cook most of my meals, and care for an active Havanese puppy who’s walked four times a day and runs free in the park every morning.

I have yet to retire and still work part time writing a weekly column, though I’ve resisted the temptation to write another book, choosing instead to enjoy more theater, opera, concerts and grandchildren, and to train the puppy to be a therapy dog.

All of which invites the question of how one defines health.

In 1948, the World Health Organization described health as “a stage of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” By that definition, I and millions of Americans like me across the age spectrum would flunk, leaving “most of us unhealthy most of the time,” as Richard Smith noted in theBMJ blog in 2008.

But disease patterns have changed since 1948. Most people, like me, are aging with chronic ailments and disabilities, yet they continue to function independently. The old definition of health “minimizes the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges,” wrote Machteld Huber and her colleagues wrote in BMJ in 2011. And the definition fails to recognize that people are able to “to function with fulfillment and a feeling of well-being” even when they have a chronic disease or disability, they wrote.

Dr. Huber and her colleagues went on to note that the ability to continue to participate in society might be more important than measured gains in health. The ability to cope with life’s ailments might be more a more important and realistic measure of health than complete recovery.

Which leads to a sober reassessment of all we do to find and treat health problems or head them off at the pass. The widespread belief that medicine today has the potential to prevent most health problems or detect them early enough for a cure has succeeded in “medicalizing” modern life and raising the costs of medical care to unsustainable levels.

It has also prompted Dr. H. Gilbert Welch, a professor at Dartmouth Medical School, to write “Less Medicine, More Health: 7 Assumptions That Drive Too Much Medical Care.” A primary care physician and health policy wonk, Dr. Welch submits that too many people are being tested for too many things, being subjected to treatments they do not need and, in the process, being exposed to procedures that may do more harm than good.

One assumption, that all risks can be lowered, can create risks of its own. Case in point: A belief (sadly mistaken) that the measles vaccine is hazardous has sparked a mini-epidemic of a potentially life-threatening disease that had been eliminated from these shores 15 years ago.

Dr. Welch suggests focusing on reducing big risks and ignoring those that are average or lower. “Many health risks you hear about are exaggerated,” he wrote. “Interventions to reduce average risks can create as many problems as they solve.”

Another assumption, that it is always better to fix a problem than to manage it, has fostered a different epidemic: the ballooning and stenting of every coronary vessel found to have a partial blockage in patients with stable angina. However, as a randomized clinical trial showed, patients treated with medications to control blood pressure and cholesterol were no more likely to suffer a heart attack or die than those who underwent an angioplasty. Only if symptoms of cardiac pain persist is a more invasive procedure justified, Dr. Welch said.

Perhaps Dr. Welch’s most controversial “assumption” is that detecting a potential health problem early is better than waiting until it produces symptoms. The value of screening people without symptoms is perhaps the most hotly debated issue in modern medicine. Should every woman over 40 have an annual mammogram? Should every man over 45 get an annual PSA test for prostate cancer?

It makes intuitive sense that early cancer detection and treatment are lifesaving. But what if the cancer would never have become a threat to life? To this day, I don’t know if my cancer would have been deadly had I not had surgery and eight weeks of radiation. But once I knew it was there, I had little choice but to treat it.

Men with PSA readings on the rise face an even more challenging decision since definitive treatment, usually surgery or radiation of the prostate, can leave them impotent and incontinent.

Dr. Welch submits that sometimes early diagnosis does little more than turn people into patients for more years. “Action,” he wrote, is not reliably the ‘right’ choice.” Sometimes it’s best to “don’t just do something, stand there.” The problem, of course, is knowing when it is safe to just monitor a disease and treat only if it progresses.

So, if not modern medical care, what really determines how healthy people are? The W.H.O. now recognizes that the following factors can have as big an impact, or bigger, on our health than access to and use of health care services:

■ Income and social status, the higher the healthier.

■ Education, likewise the higher the better.

■ Physical environment — safe water, clean air, wholesome workplaces, safe homes and well-designed communities.

■ Social support networks, including family, friends and community.

■ Genetics, which influences life span and the risk of developing certain diseases.

■ Gender — men and women face different health risks at different ages.

■ Personal behavior and coping skills, including smoking, drinking, eating, physical activity and dealing with stress.

“One of the keys to health is not to obsess about it,” Dr. Welch said in an interview. “A lot of medical care doesn’t help people. We need to be more cautious about being medicalized when we’re well. We need to think about options and not necessarily jump to the most aggressive one, which can have the most side effects.”