The Art of Manliness - Overdiagnosed — How Our Obsession with Medical Testing and Labels Is Making Us Sicker

00:00:00.000 Brett McKay here, and welcome to another edition of the Art of Manliness podcast.

00:00:11.640 Modern medicine has given us incredible tools to peer inside the body and spot disease earlier

00:00:15.980 than ever before. But with that power comes a problem. The more we look, the more we find.

00:00:21.640 Not everything we find needs fixing. My guest today, neurologist Dr. Susanna Sullivan,

00:00:26.580 argues that our culture of over-diagnosis is leaving many people more anxious,

00:00:31.000 more medicalized, and sometimes less healthy. In her book, The Age of Diagnosis,

00:00:35.560 How Her Obsession with Medical Labels is Making Us Sicker, she explains how screening tests,

00:00:39.980 shifting definitions of normal, and the rise of mental health labels can turn ordinary struggles

00:00:44.220 and idiosyncrasies into problems in need of treatment. We dig into everything from cancer

00:00:48.680 and diabetes to Lyme disease and ADHD and discuss how diagnosis really works, why screening can

00:00:53.480 sometimes harm as much as it helps, and how to know when a label is and isn't useful.

00:00:57.940 After the show's over, check out our show notes at awim.is slash diagnosis.

00:01:13.780 All right, Susanna Sullivan, welcome to the show.

00:01:17.240 Thanks for having me.

00:01:18.140 So you are a neurologist, and you've got a book out called The Age of Diagnosis,

00:01:24.380 How Our Obsession with Medical Labels is Making Us Sicker.

00:01:27.600 And you're making the case that in the past few decades, we've developed this culture in the West

00:01:34.640 where you have patients who are actively seeking medical diagnoses for things they might not have

00:01:41.800 thought about addressing a few decades ago.

00:01:44.680 And this might actually be doing us more harm than good.

00:01:49.440 And so in your book, you talk about overdiagnosis.

00:01:52.300 What do you mean by overdiagnosis, and why is it a problem?

00:01:55.920 Yeah, so I think the definition of overdiagnosis is crucial here, because I think a lot of people,

00:02:01.180 if they hear overdiagnosis, their mind immediately goes to this idea that,

00:02:05.340 oh, there's nothing wrong with that person.

00:02:06.760 They've been diagnosed, and they're complaining about nothing.

00:02:09.580 But that's really not what overdiagnosis is.

00:02:13.480 Overdiagnosis could mean that someone is really suffering, and they definitely have a problem,

00:02:18.320 but that medicalizing that problem is doing more harm than good.

00:02:22.840 So if I give you a couple of examples, it can happen in different ways.

00:02:26.320 So one way that overdiagnosis occurs is overdetection.

00:02:31.240 So now we've got all these amazing tests we can do.

00:02:33.760 We have MRI scans.

00:02:35.640 We have blood tests that weren't available decades ago.

00:02:39.300 The consequence of those tests is that we can pick up diseases and abnormalities at earlier and earlier stages.

00:02:46.520 And when we do that, we usually treat everything that we find.

00:02:49.720 But not everything that we find was inevitably going to cause a medical problem in the long run.

00:02:54.720 So not everything we find actually needs to be treated.

00:02:57.220 So that's kind of overdiagnosis by overdetection, treating things that are there but did not necessarily need to be treated

00:03:04.820 and wouldn't have caused health problems if left alone.

00:03:08.140 And the second way that we get overdiagnosis is through overmedicalization.

00:03:13.040 So that's where you begin applying medical labels to things that may really just be ordinary types of suffering.

00:03:21.820 So that may be giving mental health labels, for example, to people who are genuinely suffering.

00:03:27.220 But it may be that that suffering is better addressed through examinations of life, such as, you know, changing your work circumstances or changing your relationship rather than referring to that suffering by a medical label.

00:03:40.900 So it's really sort of overdiagnosis doesn't mean that a person doesn't have a problem, but it's asking the question whether referring to that problem as medical, is that really the right thing to do?

00:03:50.500 And I also want to, I'm a terrible talker and you may often need to interrupt me, but at the outset you said that we are seeking this out.

00:04:00.100 I'd have to say that that's not my perception.

00:04:02.320 I think it's a kind of a collusion between scientists and doctors and the public.

00:04:07.100 We've got tests and we want to do them and we want to find diseases at earlier stages.

00:04:12.580 We are calling people forward to be medicalized, but people are equally coming forward quite willingly and allowing that to happen to them.

00:04:22.380 That was one of the big takeaways that I got from your book was that one of the reasons why this overdiagnosis is happening is that we just have these tests that are available to us that weren't available decades ago.

00:04:35.100 And I think what it's done, and you talk about this in the book, is that it's really maybe distorted the layperson's idea of how a diagnosis is supposed to work.

00:04:47.400 So I think now with these tests, we think, well, you just take a test.

00:04:50.240 You do the MRI, you do the blood test, maybe answer a few diagnostic questions, and then the doctor gives you this definitive diagnosis.

00:04:58.660 But you argue with any medical diagnosis, there's an interpretive element to it.

00:05:05.520 It's not just a subjective test.

00:05:07.220 Can you explain what people misunderstand about how diagnoses are actually made?

00:05:12.200 Yeah.

00:05:12.620 So, I mean, a diagnosis is much more of a clinical process.

00:05:17.560 So that means that you have a complaint, it's a pain or it's a lump or something along those lines.

00:05:22.920 And through the doctor listening to the story of what happened to you and examining you, they form a theory about what the diagnosis might be.

00:05:31.340 And then the test, and I think people often think the test is then done to make the diagnosis.

00:05:36.540 But really, the test is done in order to help with the clinical diagnosis a doctor has already made.

00:05:43.320 Now, the important distinction here is that tests are meaningless without that first part of the stage.

00:05:48.820 And I think MRI scans are a great example of this.

00:05:52.300 So I have to always remind people that MRI scans only came into regular clinical use in the 1990s.

00:05:59.140 So we've really only been using them in clinics for actually a relatively short amount of time.

00:06:06.240 And the early MRI scanners weren't very strong.

00:06:08.660 So the new scanners have only been around for 10 or 20 years.

00:06:12.860 Before we had an MRI scan, it wasn't possible to look inside a healthy person safely.

00:06:19.820 We didn't know what the inside of a healthy body looked like because you wouldn't do a CT scan, a CAT scan, which is the predecessor really, well, still in use.

00:06:28.280 But you wouldn't do a CAT scan on a healthy person because it comes with a big dose of radiation.

00:06:33.320 So you only did CAT scans if you really needed to.

00:06:36.160 The consequence of that is we didn't really know what the inside of the healthy body looked like until we began doing regular MRI scans.

00:06:42.580 And we'd never seen the inside of the healthy body in high definition until we got the MRI scan.

00:06:48.500 Another thing I remind people then is look at how different we are on the outside.

00:06:52.940 Most of us have two eyes, two ears.

00:06:55.120 You know, we are basically the same.

00:06:57.300 And yet we are completely different on the outside.

00:06:59.860 We are also different on the inside.

00:07:02.580 So we suddenly have this technology that allows us to look at the inside of the healthy body as we never could before.

00:07:08.020 And we're suddenly finding all these differences that we, quite frankly, just didn't realize were there because we'd never looked at the inside of a healthy body before.

00:07:16.560 So in the same way that some of us have big noses and some of us have small noses and some of us have birthmarks and, you know, other kind of outward differences, we also have inner differences that really don't matter in any way to our health.

00:07:28.840 The minute you do a test, be it an MRI scan or a blood test or almost any test, you begin finding all these irregularities.

00:07:36.700 By the time you get into your 50s, about 50% of people have an abnormality on their MRI scan.

00:07:42.560 So what I'm trying to point out is that these tests will pick up loads of little things that doctors call incidentalomas.

00:07:49.420 So just incidental findings that don't matter to a person's health.

00:07:53.000 So the thing you find on the scan is not making a diagnosis.

00:07:57.340 It is being taken in the context of the story you told your doctor and what your doctor found when examining you.

00:08:04.760 And then the doctor dismisses or places emphasis on what they found in the test based on that story.

00:08:11.060 The tests produce red herrings all the time.

00:08:14.020 And this is the case for almost every type of test.

00:08:17.000 So doctors are constantly filtering through those red herrings based on the quality of the story that they got from you.

00:08:23.520 So it's not really a case of that you go to your doctor and they ultimately do the test to make the diagnosis.

00:08:30.120 They'll make the diagnosis clinically and then they'll use the test to help them.

00:08:33.900 So it's a real art, but the story is still really central to diagnosis.

00:08:38.220 Have you noticed that younger doctors who have gone to medical school where these tests existed, they rely more on the test than maybe an older doctor who didn't have these tests when they were coming of age?

00:08:55.040 Yeah, I absolutely have noticed that actually.

00:08:57.180 And it is a concern.

00:08:58.700 You know, I'm sort of, unfortunately, I hate to have to admit to it, I'm getting into the older doctor territory now.

00:09:03.700 You know, I'm in my 50s and I qualified as a doctor in 1991.

00:09:07.780 So I qualified just before we had a real kind of technological explosion.

00:09:12.520 And I think doctors of my era understand the clinical art and its importance a little bit more, not than all younger doctors.

00:09:22.200 But recently, qualified doctors have all these incredibly high-tech tests at their fingertips.

00:09:28.040 And I'm not sure that they've learned the art of using them as well as they could always.

00:09:34.160 Of course, there's many excellent doctors, but also there are doctors dependent on technology when I think really technology is a kind of an aid rather than something you should be dependent on.

00:09:44.580 Yeah, I noticed this.

00:09:45.580 So I had a general practitioner for a long time.

00:09:47.920 He was an older guy in his 60s.

00:09:50.240 And at the physical, we do blood work, the typical thing.

00:09:53.100 And sometimes he'd say, well, here's this thing.

00:09:54.760 It's a little out of the normal range, but it's not a big deal.

00:09:58.320 And he'd ask a few questions.

00:09:59.320 Are you experiencing any of the issues?

00:10:00.820 I'd say no.

00:10:01.460 And he'd say, okay, we'll just keep an eye on it.

00:10:03.120 You're fine.

00:10:03.880 Well, he retired.

00:10:05.400 And then I got this new general practitioner when she was younger.

00:10:09.700 She was younger than I was.

00:10:10.760 That's a weird moment whenever your doctor's younger than you.

00:10:14.120 And I went in to meet her and she's like, well, while you're here, let's just do some blood work. 0.93

00:10:18.060 And I'm like, okay, whatever, sure.

00:10:19.460 And we did it and there was some stuff that came back abnormal, not super out of the range.

00:10:25.380 And she said, okay, we got to do more tests.

00:10:28.660 I'm worried about this.

00:10:29.740 And I'm like, wait a minute.

00:10:30.980 I don't think it's a problem.

00:10:32.660 I'm not experiencing any symptoms.

00:10:33.920 Like, no, we have to do it.

00:10:35.040 And for a while there, I was kind of spooked.

00:10:37.540 I thought, oh my gosh, maybe something's really wrong with me.

00:10:40.080 I don't know.

00:10:41.160 But it was interesting.

00:10:42.820 I saw that difference between a younger doctor and the older doctor.

00:10:46.040 Maybe that's just a situation where as she gets more experience, she won't be so test happy.

00:10:53.020 Yeah, I think that probably is the case.

00:10:54.740 You know, I think medicine is still really one of those careers where maturity makes a really big difference to how you practice.

00:11:01.260 You learn from, you know, what you see regularly and you will become a little bit less trigger happy with tests.

00:11:07.520 But your story really, it illustrates the exact problem is if you do enough tests, you'll find irregularities, especially as we get older.

00:11:16.420 You know, if I do blood tests in people in their 60s, I'll rarely find that I get 100% normal tests back.

00:11:22.160 There'll be lots of little irregularities.

00:11:24.340 And that can really send a person down a rabbit hole, you know, because you have a test to check the test and then that test shows something.

00:11:31.740 And I've seen quite a lot of people going down that sort of medical rabbit hole that led nowhere.

00:11:36.460 And a lot of us would shrug it off.

00:11:38.040 You know, most of us would just say, you know, it's, you know, you're a little bit worried, but it's probably nothing.

00:11:42.480 But it can take over some people's lives.

00:11:44.800 It can be very anxiety provoking.

00:11:46.940 They can also have a lot of practical impacts on people in terms of insurance and things like that.

00:11:52.620 So we do need to be, I think sometimes people don't know what a good doctor looks like.

00:11:57.480 And I would say to people that a good doctor isn't the doctor who, when you go to them, every time you tell them you have a pain or an ache somewhere, they do a test.

00:12:06.020 That, to me, isn't the good doctor.

00:12:08.220 The good doctor is the one who listens to you and understands when to do tests and when not to do tests.

00:12:13.660 If they do tests every time, then that's a situation that concerns me.

00:12:19.220 One of the arguments you make in the book is that doctors should only give a diagnosis whenever it would be useful.

00:12:25.820 What makes a diagnosis useful or not?

00:12:29.360 So, again, you know, we're doing all these tests and we're constantly turning up irregularities.

00:12:35.560 And it's really part of the clinical acumen of a doctor to know how to communicate that to their patient and what a patient can understand.

00:12:45.940 So I think I use the example in the book.

00:12:48.560 We can do a lot of genetic tests now and people with children who have learning problems can have quite extensive genetic tests done that sometimes show up these things that we call variants of uncertain significance.

00:13:01.420 So, again, we're talking about a test here that's only been around for 20 years and is turning up results that we don't understand.

00:13:07.460 And in the world of genetics, if you get a result you don't understand, you call it a variant of uncertain significance.

00:13:13.360 Now, imagine you had a two-year-old child who's struggling a little bit and you get genetic tests and you're hoping those genetic tests will either tell you, you know, this is the problem or there is no problem.

00:13:24.940 And instead you get that middling answer, oh, your child has a variant of uncertain significance.

00:13:31.100 Now, nobody knows what that means.

00:13:32.400 Could be absolutely nothing, could be something.

00:13:34.660 The question that I'm really asking is if that test result tells you nothing, is it information that I need to pass on to you?

00:13:44.460 I don't think there's a right answer to this question, by the way, because I think it depends on the doctor and the patient and their interaction.

00:13:51.360 But if it's possible that this test result that I got back that I don't understand at all and that might be meaningless and that I can't really explain to you because its clinical significance is unknown, if I pass that on to you and you spend the next 20 years terrified for your child's health, have I really done you a favor?

00:14:10.040 Or if I withhold that information, am I being paternalistic and withholding information you might want to know?

00:14:15.600 So I think there's a real delicate balance in medicine about what information you share and what you don't share because our job is not to find lots of irregularities that we don't understand and then scare the living daylights out of our patients, which is becoming increasingly easy with all the tests we have available to us.

00:14:33.640 So in the book, you talk about different areas where we're seeing over-diagnosis happen.

00:14:37.780 Let's talk about over-diagnosis in cancer.

00:14:39.600 So I think all of us have probably seen reports that cancer rates are increasing, particularly among young people.

00:14:46.040 Do we know if cancer rates are actually increasing or is it that we're just catching more cancer because we're doing more screening?

00:14:55.160 Yeah, I think there's pretty good evidence that cancer rates are increasing.

00:14:59.160 So if I make the distinction between symptomatic cancer, so symptomatic cancer is something you found a lump where there's blood or there's pain.

00:15:06.940 So you have a symptom that draws your attention to the cancer.

00:15:10.960 And then the second type of cancer I'm going to talk about is cancer found on screening.

00:15:14.400 And that's where you're 100% healthy, you've been called forward for screening, and someone has found something that you didn't know was there.

00:15:21.820 So the first kind of cancer, symptomatic cancer, that is increasing.

00:15:25.460 You know, there is evidence that people under the age of 50, younger people than ever before, are getting cancer.

00:15:31.480 So I do think there's a real increase in cancer rates.

00:15:33.660 Maybe it's related to lifestyle, diet, obesity, etc.

00:15:37.740 But we also have a problem of over-diagnosis in this group of screened cancer.

00:15:43.980 So this is where people are being called forward and having mammography or blood tests to try and detect cancer that they haven't detected because they're perfectly well.

00:15:52.440 This type of cancer is subject to huge over-diagnosis, which I think might be a little confusing to people.

00:15:59.640 But we're back into that sort of territory of the inside of the healthy body is riddled with little irregularities.

00:16:08.620 And until we got the technology to find them, we didn't know that people lived out their lives with these super early-looking cancer cells that never grow and never cause health problems.

00:16:21.920 So if you do autopsies in lots of people who died for other reasons, you find little abnormal cells that would be technically considered to be cancerous, but they never grew enough to cause health problems.

00:16:32.820 The problem is when you do screening, you find these irregularities.

00:16:37.920 They were always there.

00:16:38.960 They were there in previous generations.

00:16:41.100 We didn't know they were there in previous generations because we never looked at them.

00:16:44.920 We started screening in, say, the 1970s.

00:16:47.500 Pre-1970s, we didn't know that people lived out their lives with little abnormal cells that never grew into anything dangerous.

00:16:54.980 Post-screening, we're now finding these things.

00:16:57.620 But we cannot tell the difference between an abnormal cell that will become malignant, life-threatening cancer and an abnormal cell that won't become malignant, life-threatening cancer.

00:17:08.220 And the consequence of that is we kind of have a tendency to treat all of them as equal when they're not really equal.

00:17:14.740 So a lot of people who are treated for cancer and screening probably would have been perfectly fine if we never treated them.

00:17:20.860 I hasten to say I don't want to put people off from screening with this conversation.

00:17:26.020 You know, if there are screening programs, it's reasonable for people to present themselves for that.

00:17:32.140 But they need to know about the uncertainties of the results so they can have a good conversation with their doctor about what they do if they got a positive result.

00:17:40.680 So, for example, if I have breast cancer screening and I was found to have an abnormal cell, I wouldn't necessarily automatically say, well, I want, you know, all bells and whistles cancer tests and treatment.

00:17:52.760 I might say, well, if it's a very small localized abnormal cell and I know about these things, perhaps can we just do another scan in two months' time and another scan two months' time after that and see if it's growing.

00:18:05.520 So there are different ways of addressing these abnormalities when they're found and that's what I want people to take away from this.

00:18:11.780 Yeah, so watch and wait.

00:18:13.820 Exactly, watchful waiting.

00:18:14.980 What's interesting, though, with all this, and this is kind of counterintuitive because I had a hard time wrapping my head around this, is that overall mortality rates for cancer are down.

00:18:26.480 And so people would think, well, that's because, you know, we're just catching this stuff earlier, so the early screenings work.

00:18:31.940 But that's not entirely what's going on.

00:18:33.600 So what is going on?

00:18:34.920 Well, it's a little bit of mixture of things and it is kind of a hard thing to wrap your head around.

00:18:38.780 And certainly people are surviving from, say, symptomatic cancers, so cancers that unequivocally need to be treated.

00:18:44.700 People are surviving better because cancer treatments are better.

00:18:47.500 You know, there used to be no treatment for melanoma and now there is a treatment.

00:18:51.240 So, you know, treatments for cancer are getting better.

00:18:54.760 However, we also have these sort of really kind of difficult to interpret cancer survival statistics from people who are getting diagnosed with cancer from screening.

00:19:05.420 So just imagine that you screen a thousand people for cancer and let's say a hundred of those were destined to get symptomatic cancer at some point in their lives.

00:19:16.340 But you overdiagnose 300 people and you treat all of those 300 people for cancer.

00:19:23.020 Well, 200 of those 300 were never going to get symptomatic cancer in the first place.

00:19:28.320 But if you now look at how successfully you treated those people, the results will look really optimistic.

00:19:34.780 They were never going to get cancer.

00:19:36.640 Therefore, they didn't get cancer and therefore they didn't die of cancer, but they were never going to anyway.

00:19:41.580 I hope I'm making sense here because it's, you know, if you overdiagnose people with cancer and you treat too many people for cancer, you will make cancer survival statistics look a lot better than they actually are.

00:19:53.600 And that's why a more useful way sometimes at looking at how successfully we're treating cancers that are found on screening is to look at what we call all-cause mortality.

00:20:04.460 So you can look at one of two things.

00:20:05.960 Did they die of cancer?

00:20:07.180 Well, one would hope if you're overdiagnosing cancer that the answer to that question would be no.

00:20:11.900 So let's look instead at this thing called all-cause mortality.

00:20:15.000 So deaths for any reason.

00:20:16.480 And there was a really sobering study published, I think it was in the Journal of the American Medical Association in 2023, in which they looked at all-cause mortality for people who'd been diagnosed with cancer and screening for a whole bunch of cancers like colon, prostate, breast.

00:20:32.900 And they found that they had not prolonged any lives in most of the groups through cancer screening.

00:20:40.140 In the colon cancer group, they had prolonged life by three months, but in the other groups like prostate and breast, people did not live any longer courtesy of their screening and cancer diagnosis.

00:20:51.280 And the reason for that is if you're overdiagnosing, so you screen people, you save somebody's life for sure.

00:20:58.040 So you found somebody who had cancer that was going to grow, you found it, you treated it, you saved that life.

00:21:03.420 But probably there are 10 or 20 other people who you treated who never needed to be treated.

00:21:10.660 And now you have negatively impacted the health of those 20 people.

00:21:15.820 So you've saved one person's life, but you have affected the health negatively of 20 or 30 other people who might die of complications of treatment, for example.

00:21:26.380 So you're saving some lives, but you are having a very negative impact on others.

00:21:30.980 So it's a kind of zero-sum game, you know, yes, some people are safe, but other people are given unnecessary treatment that is dangerous to them.

00:21:39.880 Yeah, cancer treatment is rough.

00:21:41.880 Yeah, you know, people always relate very strongly to the life that was saved in these questions, because we all know people with cancer and we know people who've died of cancer.

00:21:50.940 And it's a very frightening thing.

00:21:52.680 I don't think we think long or hard enough about the people who got the unnecessary treatment, because, you know, radiotherapy, chemotherapy, operations, these are really enormous things physically.

00:22:05.880 But also the psychological impact of being told you have cancer is absolutely enormous.

00:22:11.000 And then we've got the kind of financial impact in terms of insurance or jobs or applying for mortgages going forward.

00:22:17.840 So we've got a very kind of strong focus on saving that one life.

00:22:22.400 And I think we have an unnecessarily kind of blasé attitude to that overdiagnosed group.

00:22:30.200 One area in cancer where you see a lot of overdiagnosis due to screening, there's a lot of debate around it, is prostate cancer.

00:22:38.540 Why is prostate cancer so prone to overdiagnosis?

00:22:42.300 Yeah, I mean, you know, so prostate cancer, it's because the type of screening they do for prostate cancer at the moment.

00:22:50.160 Now, this will change and people are working on improving this.

00:22:53.440 But at the moment, the most common type of screening is just to measure a blood test for a prostatic specific antigen.

00:23:00.580 So this is sort of a blood test that if it is elevated, it doesn't mean you definitely have prostate cancer, but it means that you could potentially have prostate cancer.

00:23:10.160 The problem with that test is it's just completely unreliable.

00:23:14.580 You know, I draw people's attention to the fact that there is no national screening program for prostate cancer in the U.S. or in the U.K. or in most countries in the world.

00:23:24.480 And that's because this particular test has such a reputation for overdiagnosis.

00:23:29.600 You know, studies are really differ on these statistics, but to give people a rough idea, if you screen a thousand men for prostate cancer using PSA, you will likely save one life, but you will probably find an elevated prostate in about 240 or 250 people.

00:23:47.280 That's a lot of men who are now kind of going to go on a diet.

00:23:51.700 They won't all be diagnosed with prostate cancer, but they will all be started on a kind of diagnostic odyssey of do they, don't they have prostate cancer and tests and screening.

00:24:00.640 A small number of them will have biopsies and a small number of them will be told that they do have prostate cancer.

00:24:06.360 But most of those never needed to know that because as men get older, a huge number of them develop cancerous cells in the prostate that never progress.

00:24:17.860 So there was an interesting study done in Detroit where the autopsies were done on people who had died in accidents and things unrelated in any way to the prostate.

00:24:27.700 And they found that 45% of men in their 50s have abnormal cells in the prostate and 60% of men in their, might have that statistics, might be slightly low actually, of men in their 60s have abnormal cells in the prostate.

00:24:41.280 So as men get older, they all get abnormal, a large number get abnormal cells in the prostate.

00:24:46.740 And once you start screening for that using prostate specific antigen, you'll overdiagnose lots and lots of men.

00:24:52.800 So the unreliability of the test is the reason we don't do this.

00:24:56.120 Now, I think the solution to this is to screen the right people.

00:25:01.040 So there are men who are at higher risk of prostate cancer than other people, people with family history of prostate cancer, for example.

00:25:07.700 Black men are more likely to have prostate cancer.

00:25:10.480 So you can still do screening, but screening is more meaningful if it's done in people who are at high risk.

00:25:17.740 Whereas if it's done in people with low risk, it can produce very unpredictable results.

00:25:22.500 And also, if a person is really concerned about their health, they may still wish to discuss getting a PSA test with their doctor.

00:25:29.720 But it's important they know before they have that test done how uncertain the interpretation of the results will be.

00:25:37.080 Know yourself in a sense.

00:25:38.540 You know, are you the kind of person who, if they get that abnormal result back, will struggle to live with that knowledge?

00:25:44.180 Or are you the sort of person who can enter a watchful waiting program and not worry too much?

00:25:48.760 So it's all about knowledge so you know what to ask and knowing whether you can handle the information that you get back.

00:25:55.780 Yeah, I got an example of someone who had a deleterious outcome because of a PSA test.

00:26:00.700 So he's in his 50s, got the PSA, it was elevated, and the doctor's like, I'd like to do a biopsy.

00:26:07.200 And for those who don't know, biopsies, they basically stick a needle through your rectum to your prostate and then extract some tissue.

00:26:14.740 And he's like, I don't want to, no, I don't think so.

00:26:16.980 I don't think I have prostate cancer.

00:26:18.380 I'm healthy.

00:26:19.080 I don't have a history of it.

00:26:20.120 And the doctor's like, no, you need to do it.

00:26:21.100 And so he did it, and he ended up getting sepsis from the biopsy.

00:26:26.000 And he was in the hospital for a few weeks, and he didn't end up having prostate cancer.

00:26:30.140 There was nothing there.

00:26:31.440 Well, that's it precisely.

00:26:33.140 I mean, you know, you will save the occasional life through this type of screening, but you will send a lot of people on this very, very unpleasant road of tests.

00:26:42.500 So they're working, obviously, very hard on improving this screening.

00:26:46.360 And in the future, I hope that things will be better.

00:26:48.520 But at the moment, there is no national screening program for a reason, and that's worth thinking about.

00:26:54.600 We're going to take a quick break for your words from our sponsors.

00:26:56.620 And now back to the show.

00:27:01.120 You mentioned colon cancer, and there's been more of a push in the past decade or so to get a colonoscopy.

00:27:08.260 But I think the recommendation for the age to get your first one has been lowered.

00:27:12.620 It used to be 50.

00:27:14.600 Now it's 45, at least here in America.

00:27:17.660 Yeah, we don't have colonoscopy as a standard screening tool in most countries.

00:27:23.380 It's usually testing for blood in your feces.

00:27:27.520 And if there's blood there, then that potentially is symptomatic cancer, but it could also be hemorrhoids.

00:27:32.960 So that's the usual type of screening that it wouldn't be to go straight to colonoscopy.

00:27:37.860 Because colonoscopies, you know, that's an unpleasant test that comes with risks of things like perforation.

00:27:43.520 You don't want to leap into that unless you have a family history.

00:27:47.160 Again, we're always back to this sort of, these things need to be made.

00:27:51.660 These decisions need to be made in the context of risk.

00:27:54.560 It's like, what's your clinical story?

00:27:56.480 What's your story?

00:27:57.180 What's your background?

00:27:58.100 If you've got a family history of colon cancer, then you're in a high-risk group.

00:28:02.280 And then certainly colonoscopy is something you'd want to consider.

00:28:05.420 But if you're someone who's very healthy with a very healthy diet who is asymptomatic, 1.00

00:28:10.020 then that may be not something you want to consider.

00:28:12.220 Yeah, that's something that's interesting.

00:28:13.600 I've noticed America tends to be screening-happy.

00:28:17.360 We love our tests, and not so much in Europe.

00:28:21.320 Yeah, well, do you know what?

00:28:22.420 We do a fair bit of screening as well, but I think you're right.

00:28:26.240 We're not quite as, I think it's how, to a certain degree, it's how our health services differ.

00:28:30.700 But, you know, we, in the National Health Service, in a way, I consider myself to be protected by the NHS from over-diagnosis.

00:28:40.660 Because, you know, there's no, you can't have a test on demand.

00:28:44.040 We're much less likely to have whole-body MRI scans or to have MRI scans if you have no or minimal symptoms.

00:28:50.840 And I'm quite happy with that turn of events because the more tests you have, the more likely you are to find these incidental OMA things.

00:28:59.120 And I think that one really sobering study was in the New England Journal.

00:29:04.080 I've forgotten the date of it now, but very, very recently, in the 2020s, roughly.

00:29:08.640 And they looked at cancer diagnosis in high-income countries, like the US, for example, versus low-income countries.

00:29:14.780 And what they found was that, yeah, people live longer in high-income countries.

00:29:18.720 Well, that's not surprising.

00:29:20.000 You know, you don't only have better healthcare, you also have better lifestyles, etc.

00:29:24.100 But they found something else that is worrying.

00:29:26.800 They found that much more people were being diagnosed with cancer in the high-income countries than in the low-income countries.

00:29:34.080 But the cancer survival rates for those cancers were actually quite similar.

00:29:38.100 So, it seemed like a lot of people in high-income countries, by virtue of having more tests and more high-quality tests, are being diagnosed with cancer potentially unnecessarily.

00:29:50.520 No extra lives were saved by all the extra cancers being diagnosed.

00:29:54.440 The paper estimated that, you know, for every cancer diagnosis through all of this availability of technology, 10 probably weren't necessary.

00:30:02.080 So, you know, I know that the NHS has a great deal of problems.

00:30:08.600 It needs to be a lot better funded than it is.

00:30:12.300 But there is something to be said for the lack of financial dealings between patient and doctor.

00:30:18.940 You know, a patient comes to see me.

00:30:21.080 The diagnosis is dependent on nothing but the story that they tell me.

00:30:24.600 I have no, they're not my customer.

00:30:26.560 I don't need them to come back to me to be paid and so forth.

00:30:29.320 And there's something in this kind of financial transaction between patient and doctor that is potentially harmful.

00:30:35.460 And I don't think people always realize that.

00:30:38.160 Another area you talked about where there could be some over-diagnosis going on is diabetes.

00:30:44.280 And it's because the diagnostic boundaries have shifted in the past, I think, decade.

00:30:50.900 What was that change and how has that led to over-diagnosis?

00:30:55.520 Yeah, so this is a trend in medicine in multiple different areas of medicine.

00:30:58.980 So, you know, there's lots of medical problems, which the diagnosis isn't based on there being an abnormality.

00:31:04.820 It's based on drawing a line between normal and abnormal.

00:31:08.140 Like what level of blood sugar are we willing to accept as normal?

00:31:11.640 What level of blood pressure are we willing to accept as normal?

00:31:14.940 And we've had this assumption in medicine that if we kind of keep moving that, if we can detect more and more people with borderline diabetes or borderline hypertension or borderline obesity, borderline mental health problems, that we will help more people.

00:31:31.960 And therefore, we keep adjusting the line between normal and abnormal to diagnose more and more people.

00:31:37.440 So I think it was in about 2003, we had created this condition called pre-diabetes.

00:31:43.600 So this isn't diabetes.

00:31:45.100 This is a kind of borderline state between being perfectly healthy and potentially going on to develop diabetes.

00:31:51.640 In 2003, they made this slight adjustment to the measure that would allow a diagnosis of pre-diabetes.

00:31:58.780 And then a fasting blood glucose, you fast, you have your blood sugar taken.

00:32:03.900 And on one day in 2003, if you had a measure of 6.1 millimoles per liter of fasting blood glucose, you were healthy.

00:32:11.120 But then they adjusted that and said, no, 5.6 will be the new cutoff.

00:32:16.360 So it's just a small change.

00:32:17.960 You know, one day 6.1 is normal.

00:32:19.900 The next day 5.6 is normal.

00:32:21.820 But the result of that is that if the changes in the way that pre-diabetes was diagnosed was applied to everybody in the world,

00:32:31.060 this small adjustment, along with some other changes in how the diagnosis was made,

00:32:35.900 would mean that half of Chinese adults would be pre-diabetic and a third of U.S. adults would be pre-diabetic.

00:32:43.100 So kind of you're sitting at home minding your own business, essentially, and you feel you're perfectly healthy.

00:32:47.920 And meanwhile, somewhere in the background, a committee is convening and deciding, you know, what counts as normal glucose.

00:32:54.940 And on a Monday, they change it, and suddenly you are no longer healthy.

00:33:00.280 Now you are a patient.

00:33:01.840 And this is done with very good intention.

00:33:04.780 It's because, well, now we've recognized loads of more people with pre-diabetes.

00:33:08.420 We can stop people getting diabetes.

00:33:10.760 The problem is that it's not working.

00:33:13.880 The rates of diabetes are rising all the time, even though for 20 years we've had escalating diagnoses of pre-diabetes.

00:33:21.160 And this is really the absolute definition of over-diagnosis.

00:33:24.940 Is you identify more and more and more patients, but you're not actually making people healthier.

00:33:30.340 And it may be that they're not following the advice that they were given, for example.

00:33:34.000 But what is clear is that this kind of growing group of people with pre-diabetes is not benefiting them to know that.

00:33:43.000 Yeah.

00:33:43.380 And when it's about pre-diabetes, it's in this weird gray area.

00:33:47.260 Because it's not officially a diagnosis, but then people treat it like a diagnosis.

00:33:52.240 They think of themselves as a patient.

00:33:53.320 Well, I have pre-diabetes, and I have to do certain things to make sure I don't get full-blown diabetes.

00:34:00.960 Yeah, that's it.

00:34:01.740 It's a weird sort of like it's not actually a disease, pre-diabetes.

00:34:05.340 It's like a pre-disease state, but it sounds very much like a diagnosis.

00:34:09.780 And in one sense, it could be a great thing.

00:34:11.640 So it depends really on your mindset and your lifestyle and how you respond to news.

00:34:15.460 You know, if I was told that I had pre-diabetes, then perhaps I would respond by improving my diet and exercising a bit more and trying to lose some weight.

00:34:25.040 And, you know, it could have a really positive impact on me.

00:34:27.240 It could be a really good thing for my long-term health.

00:34:31.720 But somebody else might respond differently to that.

00:34:33.780 If you take a healthy person and tell them, you know, now because of this blood test, I consider you a patient, that can have a very negative impact on other people.

00:34:42.380 It can affect, if you turn a person into a patient, they can start behaving like a patient.

00:34:47.280 They begin noticing things about their body.

00:34:50.380 You know, being told that you're unhealthy turns your attention inwards to your body.

00:34:54.120 And then you start noticing little things and worrying about symptoms you didn't worry about before.

00:34:59.780 You know, in a sense, the creation of pre-diabetes, we created it to protect people's long-term health.

00:35:05.960 But we've underestimated the impact of the news that you have pre-diabetes on a person, how that might affect their kind of self-concept and how it might affect how they feel about their body and so forth.

00:35:19.800 It threw me for a loop for a while.

00:35:21.720 So I remember I had some blood work done and my fasting glucose was high.

00:35:26.720 It was like 102.

00:35:28.320 And I was like, oh my gosh, I got pre-diabetes.

00:35:30.120 And I even went out and I bought a glucose monitor, started measuring my glucose every day.

00:35:34.260 And I'm like, I don't know what I'm supposed to do because I exercise, I eat right.

00:35:37.960 I don't drink.

00:35:38.980 I'm doing everything.

00:35:39.540 I'm not overweight.

00:35:41.340 And I remember I finally talked to a doctor and I was like, what do I do?

00:35:44.340 Do I have pre-diabetes?

00:35:45.560 And they're like, well, let's check your insulin.

00:35:48.240 Your fasting insulin looks good.

00:35:49.980 So you don't look like you're on the road to diabetes.

00:35:54.120 Maybe your glucose just runs a little high in the morning and that's your normal.

00:36:00.340 Yeah, well, that's it.

00:36:01.440 You know, again, I kind of remind people of how different we are on the outside.

00:36:05.260 And, you know, these sort of differences exist on the inside too.

00:36:08.900 And it doesn't have to be an abnormality.

00:36:10.580 And in a sense, you made the important point there, which is you are otherwise a very healthy person.

00:36:15.540 You know, these things have to be taken in context.

00:36:18.140 If I was told I had pre-diabetes and I was also a smoker and, you know, my father had heart disease and my mother had a stroke and I've also got borderline high blood pressure, well, then these are issues that need to be addressed.

00:36:31.280 But if you're otherwise a very healthy person with a borderline blood test abnormality, then you don't necessarily have to be so worried about it.

00:36:39.520 So we need to take these things in context and not be terrified of every abnormal result.

00:36:45.120 You mentioned high blood pressure has undergone a change similar to diabetes in how we define it.

00:36:51.260 Yeah, I mean, you know, so there's this thing sort of borderline hypertension, which I guess is the same as pre-diabetes.

00:36:57.560 You know, your blood pressure is kind of in that border area.

00:37:00.360 You're not really hypertensive, but you could spill over into that region.

00:37:03.660 The level of blood pressure required to have borderline hypertension just keeps shifting.

00:37:09.520 And in the U.S. now, borderline hypertension is a measure of 130 over 80.

00:37:15.320 Now, when I was in medical school in the 1980s, 130 over 80, you'd be delighted with that blood pressure.

00:37:21.120 That's perfectly normal blood pressure.

00:37:23.140 Whereas now, if it's a little bit higher than that, you potentially could be offered, well, you will definitely be offered lifestyle changes, but you could also be offered drug treatment for that, something which would have been considered completely normal two or three decades ago.

00:37:37.500 In Europe, we use a slightly more generous cutoff, more around 140 over 80 or 140 over 90, because these are arbitrary cutoffs.

00:37:45.700 No one knows where normal blood pressure begins and ends, so committees of experts get together and make arbitrary cutoffs.

00:37:55.000 And when they do that, when the change was made to decide that blood pressure should now be normal up to 130 over 80 and abnormal above that, that immediately made a third of American adults a borderline hypertensive, which is just astonishing statistics.

00:38:11.640 Can it really be true that a third of adults in the U.S. are borderline hypertensive?

00:38:16.900 The purpose is good.

00:38:18.200 The purpose is prevent heart disease, prevent strokes.

00:38:21.340 But how many people with borderline hypertension do you have to treat to prevent a stroke?

00:38:26.360 Well, that could be, if I treat every single person I meet with borderline hypertension, I might prevent, you know, one stroke per 1,000 people, but I might treat 150 people who never needed to be treated.

00:38:39.780 So you're always, with these adjustments, you're always saving somebody, but equally, you can be guaranteed you're overtreating a great deal, many more people.

00:38:50.540 So you're probably, you know, per life save, you're probably overtreating 100 and 150 people.

00:38:55.080 But that's, you know, that's okay if it's just a little kind of reminder to be healthy.

00:38:59.380 You know, if you're the person who goes to your doctor and they say you've got borderline hypertension and then you go home and your lifestyle is suddenly transformed by the news, well, then that's been great for you.

00:39:09.260 And I don't object to that.

00:39:11.240 But you could be the person whose life is taken over by concern about your blood pressure or who goes on tablets and gets side effects that makes you sick when you weren't sick before or whose health insurance goes so high that you can no longer afford it.

00:39:24.920 So we have to think of both sides of it.

00:39:27.620 Another area you talk about where there's a lot of overdiagnosis is Lyme disease.

00:39:33.980 Why is Lyme disease so hard to diagnose?

00:39:37.420 And why is it vulnerable to overdiagnosis?

00:39:40.640 You know what, the first thing I'd say is I don't think Lyme disease is hard to diagnose.

00:39:44.120 Lyme disease is very well defined clinical criteria and, you know, no test is 100% reliable, of course, but pretty reliable two-stage blood testing.

00:39:55.140 There's two stages of blood testing you have to make the diagnosis.

00:39:58.300 So actually, I'd say diagnosing Lyme disease is relatively straightforward.

00:40:04.180 The reason it's so overdiagnosed is twofold.

00:40:08.260 One, because Lyme disease causes a huge array of symptoms, many of which are symptoms that any one of us could, you know, have probably experienced at some point in our lives, like fatigue, joint aches and pains.

00:40:21.340 You know, just these kind of nonspecific symptoms that are part of loads and loads of different medical problems, including psychiatric problems, but also physical problems and also aging.

00:40:31.180 So these are super common symptoms.

00:40:33.200 So that makes Lyme disease very available to overdiagnosis.

00:40:36.220 If you go to your doctor tired and they can't think of any other explanation, well, Lyme disease is one that can be provided if you are desperate for an explanation.

00:40:44.760 That's one reason I think it's overdiagnosed.

00:40:46.780 It's in a world where people are suffering and want answers, it's an answer.

00:40:51.220 The other reason it's overdiagnosed is because the tests are misused, really.

00:40:56.500 You know, as I've said before, tests need to be taken in a context.

00:41:00.300 The tests for Lyme disease have lots of reasons you can have a positive test but not have Lyme disease.

00:41:05.180 So if you spent your whole life, you grew up, you know, living beside a forest in Connecticut where there's loads of Lyme disease, chances are that in childhood you were exposed to Lyme disease and developed immunity.

00:41:17.280 And later in life, if you have a blood test, you can test positive for Lyme but not have Lyme disease.

00:41:21.980 Or maybe if you're sick in some other way, you'll get a false positive on the test.

00:41:26.000 So the tests are easily misinterpreted and you've got a disease that has symptoms that overlap with so many other things.

00:41:33.980 And you've got a society that needs explanations when they're not feeling well.

00:41:39.560 And if explanations aren't readily available, then Lyme disease will account for quite a wide range of symptoms.

00:41:46.980 Then you also have an element of corruption added in here.

00:41:50.520 You know, if you have a diagnosis that is available to give to people who are desperate for an explanation and you work as a private doctor in this area,

00:42:02.220 then overdiagnosing is very, very simple because of the uncertainties in the blood tests.

00:42:07.980 Yeah, I thought it was interesting you talk about, there's a surprisingly large number of people who have been diagnosed with Lyme disease in Australia,

00:42:16.820 but Lyme disease, the bacteria that causes Lyme disease, doesn't exist in Australia.

00:42:23.120 Yeah, I mean, this really speaks to the problem.

00:42:24.980 So, you know, exactly that.

00:42:27.380 I mean, the type of the climate in Australia, the type of ticks that carry the bacteria that cause Lyme disease,

00:42:35.340 they can't survive in Australia because of the climate.

00:42:38.580 And therefore, nobody has ever found the bacteria in any ticks that live in Australia.

00:42:43.280 And yet there's something like a half a million people in Australia who believe they contracted Lyme disease in Australia,

00:42:49.820 which is fundamentally impossible.

00:42:52.260 And yet people are getting these diagnoses.

00:42:54.720 But, you know, there's similar very high misdiagnosis rates in the US.

00:42:59.120 So a specialist Lyme disease clinic reviewed the diagnosis of a large thousands,

00:43:06.020 I think it was 5,000 people who had a diagnosis of Lyme disease, went to this specialist Lyme disease clinic,

00:43:11.560 and they determined that 85% of the people who thought they had Lyme disease did not have Lyme disease.

00:43:17.460 So this is a diagnosis that is overused at an enormous rate.

00:43:21.280 And it's estimated that about 60,000 people test positive in a proper lab that is making the diagnosis correctly in the US,

00:43:30.880 60,000 people per year.

00:43:32.600 And yet something in the region of half a million people are being treated for Lyme disease.

00:43:36.980 So the number of people being overdiagnosed is very high.

00:43:39.860 And I think that's because it's an available explanation for symptoms that people struggle to explain.

00:43:45.460 And I think it's also because there is a problem with people essentially giving out slightly over exuberant diagnosis for monetary reasons.

00:43:57.840 What do you think is going on with these people who, you know, they get the diagnosis of Lyme disease,

00:44:03.480 but maybe they don't have it.

00:44:04.440 Like they do the test and they don't, there's like, okay, you don't, there's no way you could have Lyme disease.

00:44:08.580 But they're obviously suffering.

00:44:10.220 You know, they've got the fatigue, the joint pain, brain fog.

00:44:13.720 Like a similar thing happened with people after COVID.

00:44:17.340 You know, like I got, you know, this whole idea of long COVID.

00:44:20.280 They're obviously suffering.

00:44:22.700 So what do you think is going on?

00:44:24.440 Yeah, I think, I mean, that's a super important point to emphasize, which you just did,

00:44:28.140 which is to say that someone has been misdiagnosed doesn't mean they're not suffering.

00:44:31.680 But yes, so there's at any one point in time, there's a lot of people who are suffering with nonspecific symptoms like headaches,

00:44:39.700 difficulty sleeping, joint pains, tiredness.

00:44:42.460 And those people will be given a diagnosis that sort of makes sense at a particular point in time.

00:44:48.340 And as you said, during a COVID pandemic, if you have that collection of symptoms,

00:44:52.140 you'll be, could be told you have COVID or long COVID.

00:44:55.160 You know, if you live beside a forest filled with Lyme disease or in a period when Lyme disease is common,

00:45:00.520 you'll be given Lyme disease as a diagnosis for the exact same symptoms.

00:45:04.740 What is going on with these people?

00:45:06.580 Well, there's a variety.

00:45:07.680 People are probably just hard to diagnose.

00:45:10.000 They have something that we have not yet fully understood, like an autoimmune condition that we don't yet fully understand.

00:45:16.600 But I would suspect that the largest proportion of these people probably have what I would refer to as psychosomatic symptoms.

00:45:24.500 So I'm a neurologist.

00:45:25.460 This would be something I would see very often.

00:45:27.440 So a lot of people in response to stresses or anxiety or difficult lives or unhealthy lives develop nonspecific symptoms.

00:45:37.880 So we've all had this experience.

00:45:39.580 You know, if you're stressed, you get a headache.

00:45:41.540 Or if you're just very tired or not looking after yourself, you're more likely to pick up colds and flus or you get aches and pains.

00:45:50.240 So our bodies are very vulnerable to developing physical symptoms in response to psychological stressors.

00:45:58.040 And very common symptoms in that context are things like tiredness and aches and pains.

00:46:02.580 I actually see people with much more extreme versions of this, with seizures, paralysis, blindness, and so forth.

00:46:09.420 I think a great many of these people have psychosomatic symptoms.

00:46:12.140 But we live in a society that looks down on psychosomatic symptoms.

00:46:18.360 So, you know, if somebody is very sick, if they're bedbound because they feel so bad, they literally can't get out of bed,

00:46:25.360 and you learn that the problem has more of a psychological cause than a physical cause, that's looked down on.

00:46:30.380 You know, we don't have a lot of respect for that.

00:46:32.580 And that pushes people into the need to find an explanation that society is more understanding of.

00:46:38.640 And usually that's a physical disease.

00:46:41.060 So I think there's a lot of people who have an array of physical symptoms that probably arise out of psychological distress,

00:46:47.760 but which are diagnosed as a disease because that's the culture we live in.

00:46:52.640 You know, psychological suffering is not respected to the same degree as physical disease.

00:46:57.660 And you talk about once someone gets a medical, a biological diagnosis for what could be psychosomatic,

00:47:06.340 it causes the nocebo effect where you start paying more attention to your body and thinking,

00:47:13.820 oh, this shows that I have this thing.

00:47:16.000 And it just sort of creates this vicious cycle downwards.

00:47:21.120 Yeah, I mean, this is the problem with all the medical labels we've been talking about.

00:47:24.420 This is the problem for the people with hypertension, the people with prediabetes, the people with cancer, etc.,

00:47:29.640 is that once you're given a medical diagnosis, it can have, you know, it's, everyone's familiar with the placebo effect,

00:47:37.060 which is if you're given a tablet and you believe it will work, it can alleviate your symptoms.

00:47:41.780 The exact same happens in the opposite direction referred to as the nocebo effect.

00:47:46.620 So this is where, you know, if you believe something will make you sick, it can make you sick.

00:47:51.580 I always say to people, listen, there is examples of this in everyday life everywhere.

00:47:55.400 You know, if you were about to sit down to your dinner in a restaurant and you turned around and you saw the chef coughing into the food,

00:48:01.720 it would immediately changes your experience of your body following what you've just eaten.

00:48:07.200 You know, if you eat something and then you suspect it was unhygienic after the fact, you can start feeling sick.

00:48:13.100 This is the most normal thing in the world.

00:48:15.560 So imagine now that somebody has told you that you have a disease and that it causes, you know, X number of symptoms.

00:48:21.960 You immediately kind of look at your body and begin examining yourself for those symptoms.

00:48:26.380 And I guarantee you, especially as you get older, your body is awash with things to be found if you pay enough attention.

00:48:34.520 You know, that aching knee that, you know, it only lasted a day.

00:48:37.940 Normally you dismiss it, but you've just been told you have Lyme disease.

00:48:40.860 And now you place a lot of emphasis on that aching knee, whereas you might not have worried about it yesterday.

00:48:46.900 Or, you know, some little mole on your skin suddenly gets heightened in your perspective through anxious attention.

00:48:53.240 This is the problem with medical labelling is it reinforces, it's not in everyone, but in a percentage of people, it can reinforce symptoms by turning anxious attention to your body.

00:49:03.780 And really worrying less about your health is sometimes the answer.

00:49:07.960 There's been an increase in mental health diagnoses in the past few decades.

00:49:12.920 Are there actually rising rates of mental health issues or are we diagnosing people that maybe don't need a diagnosis?

00:49:20.220 Yeah, so it's such a super hard question to answer in the sense that it's so hard to untangle.

00:49:27.120 You know, in one sense, there does seem to be evidence that suggests that particularly in the group of adolescents to young adults, say age 16 to 24,

00:49:36.540 there does appear to be more mental health issues in this group, for example, more than any other.

00:49:43.080 And that means they're more likely to go to their doctor with symptoms and also that they have more mental health symptoms.

00:49:48.620 But does that mean that there is more mental health illness in this group?

00:49:55.180 Because that can be explained in so many ways.

00:49:57.320 It could be that we've got all these awareness campaigns going now, often targeted at young people and awareness campaigns in schools that bring people's attention to mental health problems.

00:50:08.820 So are they going to their doctor because they've been given express instruction to examine themselves for problems and they're finding things we wouldn't have found before because we didn't think that way?

00:50:20.580 Are they more symptomatic because of the anxious attention that they're paying to their moods or are they genuinely more symptomatic?

00:50:27.220 So I think it's really hard to untangle to what degree is the fact that young people have more mental health problems there?

00:50:34.740 Because we have created that through awareness campaigns, through telling people to worry about small changes in mood, or is it a real increase in mental health problems?

00:50:45.480 But I think whatever conclusion you come to on that, you have to say that there is an over-diagnosis of conditions like ADHD and autism.

00:50:56.540 Now, again, I emphasize that when I talk about over-diagnosis, I'm not saying this person isn't suffering and you should ignore them and tell them to snap out of it.

00:51:04.840 That's not my attitude.

00:51:05.740 I'm saying that adolescents sometimes have struggles and by over-diagnosis, I mean medicalizing those struggles by referring to them through labels of ADHD and autism might be harmful to them.

00:51:19.240 The reason I say there's over-diagnosis is it's very hard to spot over-diagnosis in individuals.

00:51:24.340 So let's say you've got a 16-year-old and they've been told they have ADHD and they're validated by the diagnosis and they feel better.

00:51:31.300 Is that over-diagnosis or isn't it?

00:51:32.980 You can't really tell, but you can tell by looking at the population.

00:51:36.960 So we've been making mental health diagnosis at escalating rates since the 1990s.

00:51:42.260 We've been telling young people they have ADHD and autism at escalating rates since the 1990s.

00:51:48.080 Now, the purpose of seeking out those young people and giving them those labels is that their problems should be recognized, they should get support, and then they should be happier, healthier, better adjusted adults.

00:52:00.260 But what do we see downstream?

00:52:01.860 We've got way more teenagers getting diagnosis of ADHD and autism, but we also have way more young adults who now have mental health problems like depression and anxiety.

00:52:13.100 And that's the very definition of over-diagnosis.

00:52:16.120 It's not to say that original group who were told they had autism and ADHD didn't have a problem at all, but it seems to me that framing their problem through these lenses of autism and ADHD has not resulted in healthier and happier adults.

00:52:30.340 And we really need to rethink what we're doing.

00:52:33.100 My real fear is that you take an adolescent and you tell them that their communication problems are abnormal and due to a brain chemistry abnormality or that their sort of attentional difficulties are not because they're a teenager and teenagers have attentional difficulties, but because they have a dopamine abnormality in their brain.

00:52:52.860 Then you potentially make that problem so concrete that a child can't overcome it, adolescence is a time of change.

00:52:59.480 You should have the opportunity to mature out of your difficulties or to work on things.

00:53:04.160 And I'm afraid that because we tend to make diagnosis and then accommodate to them, we're not giving children the chance to make the changes that we all made.

00:53:15.860 People get really touchy about this, particularly around ADHD and autism.

00:53:21.900 I know it can get very heated, the debates about it.

00:53:25.880 Why do you think that is?

00:53:26.780 Yeah, I think it's mostly because people kind of understand this conversation to mean that their difficulties are being dismissed as irrelevant or they don't have struggles.

00:53:37.120 And that's certainly not how I feel about it.

00:53:39.580 I think that adolescence in particular is a real time of difficulty, but also people who are getting diagnosis in older age.

00:53:46.980 I believe the difficulties are real, but I don't think medicalizing the difficulties with these labels is the right thing to do.

00:53:55.000 So I wouldn't wish in any way for anyone to feel that I'm saying we should go back to the old days where everyone was told to snap out of it.

00:54:02.620 Or, you know, I was in school in the 80s.

00:54:05.040 You know, nobody in my class of 120 was recognized as having a special learning need.

00:54:09.420 There must have been someone, you know, so we had an underdiagnosis problem.

00:54:13.260 I'm not suggesting we should go back there, but I'm suggesting that we should think about how we are helping struggling people and ask if it's the right kind of help.

00:54:22.260 You know, is it really optimal?

00:54:25.280 I still think we should, if someone has a problem, then they need to be able to voice it and then their problem needs to be acknowledged.

00:54:32.340 But is then attaching a medical label the right way to go about things?

00:54:37.000 And I know that it can make people feel validated and I don't want to take that away from people.

00:54:42.220 But I think that a diagnosis needs to come with something more than validation.

00:54:46.040 It needs really to lead to something more positive.

00:54:50.920 Unfortunately, when you're validated by a diagnosis, it can just make the symptoms worse.

00:54:55.780 Because in order to remain validated and remain part of this new tribe that you belong to, courtesy of your diagnosis, you have to continue to not be well.

00:55:06.160 Getting well means you lose your tribe and you potentially lose your diagnosis.

00:55:10.540 So how do you get well in those circumstances?

00:55:12.640 I think we're better to frame our difficulties in terms of, you know, what in my life can be changed to make me feel better, rather than framing them through internal chemistry.

00:55:24.420 And in the case of ADHD, I mean, one of the things you do to treat it is, you know, prescribe Ritalin or Adderall.

00:55:32.200 Which, I mean, those are Schedule 1 substances.

00:55:34.000 Like, those can be highly addictive substances.

00:55:36.680 And it's like, well, maybe you don't need to get on that if you don't need it.

00:55:39.880 You know, it's interesting how badly we learned from the past.

00:55:43.960 You know, we had a whole benzodiazepine crisis in the 80s.

00:55:47.740 You know, it seemed to be a drug that did amazing things for people, but then people got highly addicted to it.

00:55:52.460 And then we had an opioid crisis.

00:55:54.680 You know, for a while, everyone thought opioids were the best thing ever.

00:55:57.900 You know, and look where that led us.

00:56:00.160 We're not very good at learning from the difficulties of the past.

00:56:03.600 You know, I'd be very loathe to take a medication that is fundamentally a stimulant, which is an amphetamine-like drug, unless I knew I had to take it.

00:56:12.820 Now, that's not to say that I don't think there's a role for medication.

00:56:15.820 There will always be people who have extreme disability.

00:56:19.560 There always are hyperactive children who are so hyperactive, they really cannot engage in education.

00:56:25.360 And they may need something to help them through a difficult period.

00:56:28.480 So I'm not a kind of never say never, but this wide prescribing of stimulant drugs seems really ill-advised to me.

00:56:36.820 So what do you think the right balance is between diagnosing too much and not diagnosing enough?

00:56:42.820 Like, what do you want readers to take away from your book the next time they're dealing with a health concern?

00:56:48.680 Yeah, so I think what's really important is, first of all, you know, that you have choices very often.

00:56:54.620 And I think that's something people don't really realize.

00:56:57.580 Most medical situations are not urgent.

00:57:00.820 So we have occasional emergencies, but most things you go to your doctor with, you can get a test result and you can think about it.

00:57:07.000 So I think that we should be creating a system of more slow medicine where you get test results back and then you consider all the variables.

00:57:14.600 Are you a high-risk person?

00:57:16.140 What else in your life might put you at risk of this particular disease?

00:57:20.200 So that you can decide whether you need to react urgently or whether you may be someone who doesn't have to worry and can go down a more watchful waiting pathway.

00:57:29.000 I think it's very useful for people to understand the uncertainties in test results because it might feel like the best thing in a certain circumstance is to have that blood test or to have the scan.

00:57:41.160 You know, a lot of neurologists wouldn't have a brain scan as it happens.

00:57:44.600 And I think it's useful for people to know that, that sometimes the scan that you have to relieve your anxiety can actually cause more anxiety.

00:57:53.780 I really want people to just do a balancing exercise when it comes to diagnosis.

00:57:58.180 Ask themselves before they get that mental health diagnosis or ADHD or autism diagnosis, if I get this diagnosis, what will I get?

00:58:06.180 What will it bring me that is positive?

00:58:07.940 And if I get this diagnosis, what are the potential negative impacts of that diagnosis?

00:58:14.820 And you really need to be sure that what you get is substantially greater than what you lose through a diagnosis.

00:58:21.120 Well, Suzanne, this has been a great conversation.

00:58:23.160 Where can people go to learn more about the book and your work?

00:58:26.000 Well, I hope everybody will buy the book, which is called The Age of Diagnosis, How Our Obsession with Medicine is Making Us Sicker.

00:58:31.840 So, you know, I feel like sometimes when I talk about this subject, people might think I'm an outlier doctor that, you know, who is this doctor coming along and saying all of these kind of slightly scary things.

00:58:43.220 But actually, everything I'm talking about is widely discussed within medicine.

00:58:47.520 We're just not having a good enough public conversation yet.

00:58:50.620 Well, Suzanne O'Sullivan, thanks for your time.

00:58:52.260 It's been a pleasure.

00:58:53.280 Thank you for having me.

00:58:55.380 My guest here is Dr. Suzanne O'Sullivan.

00:58:57.020 She's the author of the book, The Age of Diagnosis.

00:58:59.100 It's available on Amazon.com and bookstores everywhere.

00:59:01.200 Check out our show notes at aom.is slash diagnosis, where you can find links to resources and we delve deeper into this topic.

00:59:14.180 Well, that wraps up another edition of the AOM podcast.

00:59:16.900 Make sure to check out our website at artofmanliness.com, where you can find our podcast archives.

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00:59:39.500 Until next time, it's Brett McKay.

00:59:41.000 Remind you to not listen to anyone's podcast, but put what you've heard into action.

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The Art of Manliness - September 08, 2025

Overdiagnosed — How Our Obsession with Medical Testing and Labels Is Making Us Sicker

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