A 45-year-old man consults his physician, who performs blood tests. The cholesterol concentration is 230 mg/dL. While this value is about average for Americans, it exceeds the “goal” value of < 200 mg/dL. The doctor prescribes a medication to reduce cholesterol.
A 65-year-old woman consults her physician, who recommends a bone density test. At the radiologist’s office, she lies on a table while x-rays are beamed through her spine and hip. Her bone density score, while about average for her age and weight, is substantially below that of the comparison group, women aged 30-45. She is diagnosed with osteoporosis, and medication is prescribed.
So many diagnoses, so many pills. Pills for hyperlipidemia, osteoporosis, hypertension, menopause, impotence, baldness, irritable bladder, toenail fungus, obesity. For many of these diagnoses, one feels completely well. For others, one notes a change but considers it “natural,” a regular part of life that should be accommodated.
And for many of these, society first recognizes a medical condition, or recognizes that a condition is “medical,” or recognizes a “condition” at all, when a test—or a pill—or both—become promulgated. Osteoporosis was first discussed widely during the mid-1990s, when a new test, dual-energy x-ray absorbiometry (DEXA), and a new pill, Fosamax®, were introduced. Both were widely publicized, by advertising and journalistic ventures, to both physicians and the public at large. Within a few years, women and physicians were requesting DEXA on a regular basis. Abnormal DEXA results meant the prescription of medication, such as Fosamax, as well as repeating DEXA every year or two, forever.
There is a cost, of course. A single DEXA test costs about $200, and a year of Fosamax costs about $600. If these expenditures prevent hip fractures, the money is well spent. But how many women would have to be tested to prevent one fracture? Many. It is estimated that in white women aged 50-59, it would take 750 DEXA tests to prevent one hip or vertebral fracture in five years of treatment.* And there is another cost, one measured better in psychological than in financial terms. A woman who feels completely well, and who most likely would have lived her life without fracture, has been dealt a diagnosis. She thought she was well, but in fact she is sick, osteoporotic, at risk. Her life has been medicalized. Further, her health resides in a number, her DEXA score. Her relations with her body and her physician have been translated into purely quantitative terms. And one step more: a world has been created in which pill-taking is normative, necessary.
In effect, a new disease has been created by the introduction of a test to diagnose it and a pill to treat it. The industries that sell the test and the pill profit from both. But do the patients profit? And what of the doctors, themselves selling the tests, themselves selling the visits that prescribe the pills, eager to please their “well-informed” patients, eager to be up-to-date, eager to look smart, eager to help?
*Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Statement 2000 March 27-29; 17 (1): 1-36.
Charles Bardes is a physician who lives and works in New York City, where he teaches and practices general medicine at Weill Medical College of Cornell University as Professor of Clinical Medicine and Associate Dean. He is the author of Essential Skills in Clinical Medicine and articles related to medical education. (3/2006)