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

Summary

Podcast Summary

Podcast: The Art of Manliness
Host: Brett McKay
Guest: Dr. Susannah Sullivan, Neurologist
Episode: Overdiagnosed — How Our Obsession with Medical Testing and Labels Is Making Us Sicker
Release Date: September 8, 2025

---

Overview

This episode explores the theme of "overdiagnosis"—how our increasing reliance on medical tests and hunger for medical labels may be making people less healthy, more anxious, and overly medicalized. Neurologist Dr. Susannah Sullivan joins host Brett McKay to discuss her book The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker. The conversation unpacks how advances in medical tests, shifting definitions of normal, and a culture craving diagnosis are creating new problems for patients.

---

Key Discussion Points & Insights

What is Overdiagnosis? (03:19–06:23)

• Definition Nuance: Overdiagnosis does not mean someone has no problem. It refers to either:
  • Overdetection: Identifying diseases or abnormalities that would never cause harm if left undetected or untreated.
  • Overmedicalization: Applying medical labels to common life struggles or normal variations, potentially causing more harm than benefit.
• Quote:

  “Over diagnosis 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?”
  — Dr. Sullivan (05:16)

Diagnostic Process: Art vs. Science (06:23–10:40)

• Layperson Misunderstanding: Many view diagnosis as purely a technical test. In reality, diagnosis remains a clinical process—tests supplement a doctor’s judgment; they don’t determine it.
• Incidental Findings: The more tests, the more “incidentalomas” are found—abnormalities that are benign and common, especially as we age.
• Quote:

  “By the time you get into your 50s, about 50% of people have an abnormality on their MRI scan.”
  — Dr. Sullivan (09:32)

Shift from Clinical Art to Test Dependence (10:40–14:20)

• Generational Difference: Older doctors trained before high-tech tests rely more on patient history and physical exams, while many younger doctors lean heavily on tests, sometimes to the patient’s detriment.
• Patient Story (Brett): Changing from an older to a younger GP, Brett observed more test-driven, less context-aware care, which caused unnecessary anxiety.
• Quote:

  “The good doctor isn’t the doctor who, every time you tell them you have a pain or ache somewhere, they do a test... The good doctor is the one who listens to you and understands when to do tests and when not to do tests.”
  — Dr. Sullivan (13:33)

When is a Diagnosis Useful? (14:20–16:34)

• Clinical Judgment: Not all test results should be shared if they are uncertain and might cause undue anxiety.
• Ethical Dilemma: Should doctors share ambiguous results (like genetic variants of “uncertain significance”), or is it more harmful than helpful?

---

Disease Categories and Overdiagnosis

Cancer & Screening Paradoxes (16:34–28:55)

• Actual Increases vs. Overdetection: Cancer rates (for symptomatic cases) are increasing, but screening leads to large numbers of non-threatening cancers being detected and often aggressively treated.
• Survival Statistics Trap: Treating non-dangerous cancers inflates survival stats without necessarily improving actual life expectancy.
• Quote:

  “If you over diagnose people with cancer and you treat too many people... you will make cancer survival statistics look a lot better than they actually are.”
  — Dr. Sullivan (21:35)

• Prostate Cancer Example: PSA screening saves a few lives but leads to unnecessary anxiety and invasive procedures for many.
• Quote:

  “For every cancer diagnosis through all of this availability of technology, 10 probably weren’t necessary.”
  — Dr. Sullivan (34:12)

Differences in Medical Culture (33:25–35:50)

• US health model incentivizes more screening; single-payer systems like the NHS may protect patients from excessive, unnecessary testing due to less commercial motivation.

Shifting Disease Definitions: Diabetes & Hypertension (35:50–44:40)

• Diagnostic Boundaries: Lowering thresholds for prediabetes and hypertension has massively increased the number of labeled patients—yet with limited evidence that this improves health outcomes.
• Quote:

  “Kind of you’re sitting at home minding your own business… and meanwhile, somewhere in the background, a committee is convened and deciding… what counts as normal glucose. And on a Monday, they change it. And suddenly you are no longer healthy.”
  — Dr. Sullivan (37:20)

• No Clear Population Health Benefit: Dramatically more people are labeled as "at risk" without benefit to overall rates of disease prevention.

Lyme Disease & Diagnosis Demand (44:40–49:37)

• Diagnostic Overuse: Lyme disease, while having robust diagnostic criteria, gets overdiagnosed due to nonspecific, common symptoms and loose (sometimes financially motivated) testing practices.
• Astonishing Global Overdiagnosis: Instances of Lyme diagnoses in Australia, where the bacterium doesn’t exist, illustrates the dangers of overtesting.
• Quote:

  “A specialist Lyme disease clinic… determined that 85% of the people who thought they had Lyme disease did not have Lyme disease.”
  — Dr. Sullivan (47:57)

Psychosomatic Symptoms & Label Clustering (49:37–54:33)

• Many chronic, unexplained symptoms might be rooted in psychological stress, but our culture prefers physical disease labels, sometimes worsening the problem via the nocebo effect.
• Quote:

  “Once you’re given a medical diagnosis, it can have… a nocebo effect. So this is where… if you believe something will make you sick, it can make you sick.”
  — Dr. Sullivan (52:33)

Rising Mental Health Diagnoses (54:33–60:37)

• Unpacking the Increase: Some data suggest real rises in distress among young people, but overdiagnosis of conditions like ADHD and autism is rampant.
• Population vs. Individual Impact: While awareness and support are positive, seeing adolescent norms as medical disorders may actually increase long-term suffering.
• Quote:

  “You have to say that there is an over diagnosis of conditions like ADHD and autism… It seems… framing their problem through these lenses has not resulted in healthier and happier adults.”
  — Dr. Sullivan (56:20)

---

Thoughts on Solutions & Takeaways

The Role of Slow Medicine (62:01–63:34)

• Empowerment: Most diagnoses are not urgent; patients and doctors should take time to weigh information.
• Self-Assessment Before Testing:
  • What will you gain from a diagnosis?
  • What might you lose (anxiety, stigma, treatment risks)?
  • Is the potential benefit worth the risk?
• Quote:

  “We should be creating a system of more slow medicine… Sometimes the scan that you have to relieve your anxiety can actually cause more anxiety.”
  — Dr. Sullivan (62:25)

---

Notable Quotes & Memorable Moments

| Timestamp | Quote & Speaker | |-----------|----------------| | 05:16 | “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?” — Dr. Sullivan | | 09:32 | “By the time you get into your 50s, about 50% of people have an abnormality on their MRI scan.” — Dr. Sullivan | | 13:33 | “The good doctor isn’t the doctor who, every time you tell them you have a pain or ache somewhere, they do a test... The good doctor is the one who listens to you and understands when to do tests and when not to do tests.” — Dr. Sullivan | | 21:35 | “If you over diagnose people with cancer and you treat too many people... you will make cancer survival statistics look a lot better than they actually are.” — Dr. Sullivan | | 34:12 | “For every cancer diagnosis through all of this availability of technology, 10 probably weren’t necessary.” — Dr. Sullivan | | 37:20 | “Kind of you’re sitting at home minding your own business… and meanwhile… a committee is convened and deciding… what counts as normal glucose. And… suddenly you are no longer healthy.” — Dr. Sullivan | | 47:57 | “A specialist Lyme disease clinic… determined that 85% of the people who thought they had Lyme disease did not have Lyme disease.” — Dr. Sullivan | | 52:33 | “Once you’re given a medical diagnosis, it can have… a nocebo effect. So this is where… if you believe something will make you sick, it can make you sick.” — Dr. Sullivan | | 56:20 | “You have to say that there is an over diagnosis of conditions like ADHD and autism… It seems… framing their problem through these lenses has not resulted in healthier and happier adults.” — Dr. Sullivan | | 62:25 | “We should be creating a system of more slow medicine… Sometimes the scan that you have to relieve your anxiety can actually cause more anxiety.” — Dr. Sullivan |

---

Important Segments & Timestamps

• Introduction to Overdiagnosis: 03:18–06:23
• Diagnostic Process & Test Context: 06:23–10:40
• Cultural Shifts in Medical Testing: 10:40–14:20
• Screenings and Cancer Risks: 16:34–28:55
• National & Systemic Healthcare Differences: 33:25–35:50
• Changing Definitions: Diabetes & Hypertension: 35:50–44:40
• Lyme Disease Overdiagnosis: 44:40–49:37
• Mental Health Labels: 54:33–60:37
• Patient Empowerment & Slow Medicine: 62:01–63:34

---

Final Thoughts

Dr. Sullivan urges patients and physicians alike to slow down, question the reflex to label every variation as disease, and weigh the real-life costs and benefits of medicalizing ordinary experiences. The episode is a thought-provoking critique of modern medicine’s overzealous use of labels and tests—a must-listen for those who want to be savvier, more empowered patients.

---

Resources

• Dr. Susannah Sullivan, The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker
• More: Art of Manliness Show Notes

Transcript

[A]

School's back in session and things are busy in the McKay household between basketball practice, church activities and student council events. Some nights we just don't have time for a home cooked meal, but we also don't want to end up grabbing fast food. That's where Factor Meals comes in. Clutch Factor delivers fresh, not frozen chef prepared meals that are ready to heat and eat in just two minutes. We've been using it on our busiest nights. A few of my go to meals lately have been the Garlic Herb Chicken and the Smoky Tomato Pork Tenderloin. Both are packed with flavor and actually are satisfying, which is something I don't say lightly about most pre made meals. Eat [e-mail] Manliness 50 off and use code MANLINESS50OFF to get 50% off your first box plus free breakfast for a year. That's pretty amazing. Again, that's FactorMeals.com Manliness 50 off that's M A N L I N E S S 50 off use promo code MANLINESS50OFF to Get 50% off your first box plus Free breakfast for a year. Get delicious ready meals delivered with Factor Starting your own business means figuring out a lot of things you've probably never done before. Especially in the early days. When I launched the Art of Manliness store, I suddenly had to learn how to manage orders, track inventory, fulfill shipments, and make the whole operation look professional. It was a lot. That's why I've been using Shopify for years. It takes the chaos out of running an online store. Shopify is the commerce platform behind millions of businesses and 10% of all E commerce in the US from big brands like Gymshark to solo creators just starting out, it scales with you. You can launch a sharp looking site using their templates, use AI tools to help write product descriptions, or clean up photos and run marketing emails and campaigns all from the same dashboard. Shopify also handles payments, inventory, analytics, shipping, everything you need to run and grow.

[B]

2.

[A]

Turn your big business idea into real sales with Shopify. Sign up for your $1 a month trial and start selling today at shopify.com manliness that's shopify.com manliness S-H-O-P-I-F-Y.com manliness Check it out today. Brett McKay here and welcome to another edition of the Art of Manliness podcast. Modern medicine has given us incredible tools to peer inside the body and spot disease earlier than ever before. But with that power comes a the more we look, the more we find. Not everything we find needs fixing. My guest today neurologist Dr. Susannah Sullivan argues that our culture of over diagnosis is leaving many people more anxious, more medicalized, and sometimes less healthy. In her book, the Age of How Her Obsession With Medical Labels Is Making Us Sicker, she explains how screening tests, shifting definitions of normal, and the rise of mental health labels can turn ordinary struggles and idiosyncrasies into problems in need of treatment. We dig into everything from cancer and diabetes to Lyme disease and ADHD and discuss how diagnosis really works, why screening can sometimes harm as much as it helps, and how to know when a label is and isn't useful. After the show's over, check out our shownotes at aowim Is diagnosis. All right, Susannah Sullivan, welcome to the show.

[B]

Thanks for having me.

[A]

So you are a neurologist and you've got a book out called the Age of Diagnosis, How Our Obsession With Medical Labels Is Making Us Sicker. And you're making the case that in the past few decades, we've developed this culture in the west, where you have patients who are actively seeking medical diagnoses for things they might not have thought about addressing a few decades ago, and this might actually be doing us more harm than good. And so in your book, you talk about over diagnosis. What do you mean by over diagnosis and why is it a problem?

[B]

Yeah, so I think the definition of overdiagnosis is crucial here because I think a lot of people, if they hear over diagnosis, their mind immediately goes to this idea that, oh, there's nothing wrong with that person. They've been diagnosed and they're complaining about nothing. But that's really not what over diagnosis is. Over diagnosis could mean that someone is really suffering and they definitely have a problem, but that medicalizing that problem is doing more harm than good. So if I give you a couple of examples, it can happen in different ways. So one way that over diagnosis occurs is over detection. So now we've got all these amazing tests we can do. We have MRI scans, we have blood tests that weren't available decades ago. The consequence of those tests is that we can pick up diseases and abnormalities at earlier and earlier stages. And when we do that, we usually treat everything that we find. But not everything that we find was inevitably going to cause a medical problem in the long run. So not everything we find actually needs to be treated. So that's kind of over diagnosis by over detection, treating things that are there but did not necessarily need to be treated and wouldn't have caused health problems if left alone. And the second way that we get over diagnosis is through over medicalization. So that's where you begin applying medical labels to things that may really just be ordinary types of suffering. So that may be giving mental health labels, for example, to people who are genuinely suffering, 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 label. So it's really sort of over diagnosis 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? 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. I'd have to say that that's not my perception. I think it's a kind of a collusion between scientists and doctors and the public. We, we've got tests and we want to do them, and we want to find diseases at earlier and earlier stages. We are calling people forward to be medicalized, but people are equally coming forward quite willingly and allowing that to happen to them.

[A]

That was one of the big takeaways that I got from your book, was that one of the reasons why this over diagnosis is happening is that we just have these tests that are available to us that weren't available decades ago. 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. Because I think now with these tests, we think, well, you just take a test, you do the mri, you do the blood test, maybe answer a few diagnostic questions, and then the doctor gives you this definitive diagnosis. But you argue with any medical diagnosis, there's an interpretive element to it. It's not just this objective test. Can you explain what people misunderstand about how diagnoses are actually made?

[B]

Yeah. So, I mean, a diagnosis is much more of a clinical process. So that means that you have a complaint, it's a pain, or it's a lump or something along those lines. 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 and then the test. And I think people often think the test is then done to. To make the diagnosis, but really the test is done in order to help with the clinical diagnosis a doctor has already made. Now, the important distinction here is that tests are meaningless without that first part. Of the stage. And I think MRI scans are a great example of this. So I have to always remind people that MRI scans only came into regular clinical use in the 1990s. So we've really only been using them in clinics for actually a relatively short amount of time. And the early MRI scanners weren't very strong. So the new scanners have only been around for 10 or 20 years. Before we had an MRI scan, it wasn't possible to look inside a healthy person safely. 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, but you wouldn't do a CAT scan on a healthy person because it comes with a big dose of radiation. So you only did CAT scans if you really needed to. 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. And we'd never seen the inside of the healthy body in high definition until we got the MRI scan. Another thing I remind people then is look at how different we are on the outside. Most of us have two eyes, two ears. You know, we are basically the same, and yet we are completely different on the outside. We are also different on the inside. So we suddenly have this technology that allows us look at the inside of the healthy body as we never could before, 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. 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. 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. By the time you get into your 50s, about 50% of people have an abnormality on their MRI scan. So what I'm trying to point out is that these tests will pick up loads of little things that doctors call incidentalomas. So just incidental findings that don't matter to a person's health. So the thing you find on the scan is not making a diagnosis. It is being taken in the context of the story you told your doctor and what your doctor found when examining you. And then the doctor dismisses or places emphasis on what they found in the test based on that story. The tests produce red herrings all the time. And this is the case for almost every type of test. So doctors are constantly filtering through those red herrings based on the quality of the story that they got from you. So. So it's not really a case of that. You go to your doctor and they ultimately do the test to make the diagnosis. They'll make the diagnosis clinically and then they'll use the test to help them. So it's a real art. But the story is still really central to diagnosis.

[A]

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?

[B]

Yeah, I absolutely have noticed that actually. And it is a concern. You know, I'm sort of, unfortunately, I hate to have to admit to it. I'm getting into the older doctor territory now. You know, I'm in my 50s and I qualified as a doctor in 1991. So I qualified just before we had a real kind of technological explosion. And I think doctors of my era, understanding the clinical art and its importance a little bit more not than all younger doctors, but recently qualified doctors have all these incredibly high tech tests at their fingertips. And I'm not sure that they've learned the art of using them as well as they could. Always, of course, as 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.

[A]

Yeah, I noticed this. So I had a general practitioner for a long time. He was an older guy in his 60s. And at the physical we do blood work, the typical thing. And sometimes he'd say, well, here's this thing. It's a little out of the normal range, but it's not a big deal. And he'd ask a few questions. Are you experiencing any of the issues? I'd say no, and he'd say, okay, we'll just keep an eye on it, but you're fine. Well, he retired. And then I got this new general practitioner when she was younger, she was younger than I was. That's a weird moment whenever your doctor's younger than you. And I went in to meet her and she like, well, while you're here, let's just do some blood work. And I'm like, okay, whatever, sure. And we did it and there was some stuff that came back abnormal, not super out of the range. And she said, okay, we got to do more tests. I'm worried about this. And I'm like, wait a minute, I don't, I don't think it's a problem not experiencing any syndrome. Like, no, we have to do it. And for a while there, I was kind of spooked. I thought, oh my gosh, maybe something's really wrong with me. I don't know. But it was interesting. I saw that difference between a younger doctor and the older doctor. Maybe that's just a situation where as she gets more experience, she won't be so test happy.

[B]

Yeah, I think that probably is the case. You know, I think medicine is still really one of those careers where maturity makes a really big difference to how you practice. You learn from, you know, what you see regularly. And you will become a little bit less trigger happy with tests. But your story, really, it illustrates the exact problem is if you do enough tests, you'll find irregularities, especially as we get older. You know, if I do blood tests in people in their 60s, I'll rarely find that I get 100% normal tests back. There'll be lots of little irregularities. 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. And I've seen quite a lot of people going down that sort of medical rabbit hole that led nowhere. And a lot of us would shrug it off. 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. But it can take over some people's lives. It can be very anxiety provoking. They can also have a lot of practical impacts on people in terms of insurance and things like that. So we do need to be. I think sometimes people don't know what a good doctor looks like. And I would say to people that 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. That, to me, isn't the good doctor. The good doctor is the one who listens to you and, and understands when to do tests and when not to do tests. If they do tests every time, then that's a situation that concerns me.

[A]

One of the arguments you make in the book is that doctors should only give a diagnosis whenever it would be useful. What makes a diagnosis useful or not.

[B]

So again, you know, we're doing all these tests and we're constantly turning up irregularities. 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. So I think I use the example in the book. 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. 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. In the world of genetics, if you get a result you don't understand, you call it a variant of uncertain significance. 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. And instead you get that middling answer, oh, your child has a variant of uncertain significance. Now, nobody knows what that means. Could be absolutely nothing. Could be something. 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? 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. 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? Or if I withhold that information, am I being paternalistic and withholding information you might want to know? 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.

[A]

So in the book, you talk about different areas where we're seeing over diagnosis happen. Let's talk about over diagnosis and cancer. So I think all of us have probably seen reports that cancer rates are increasing, particularly among young people. Do we know if cancer rates are actually increasing or is that we're just catching more cancer because we're doing more screening?

[B]

Yeah, I think there's pretty good evidence that cancer rates are increasing. So if I make the distinction between symptomatic cancer. So symptomatic cancer is something you found a lump or there's blood, or there's pain, you know, so you have a symptom that draws your attention to the cancer. And then the second type of cancer I'm going to talk about is cancer found on screening. 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. So the first kind of cancer, symptomatic cancer that is increasing, you know, there is evidence that people under the age of 50, younger people than ever before, are getting cancer. So I do think there's a real increase in cancer rates. Maybe it's related to lifestyle, diet, obesity, et cetera. But we also have a problem of over diagnosis in this group of screened cancer. 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. This type of cancer is subject to huge over diagnosis, which I think it might be a little confusing to people. But we're back into that sort of territory of the inside of the healthy body is riddled with little irregularities. 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. So if you do autopsies and 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. The problem is when you do screening, you find these irregularities. They were always there. They were there in previous generations. We didn't know they were there in previous generations because we never looked at them. We started screening and say the 1970s, pre1970s, we didn't know that people lived out their lives with little abnormal cells that never grew into anything dangerous post screening. We're now finding these things, 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. 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. So a lot of people who are treated for cancer and screening probably would have been perfectly fine if we never treated them. I hasten to say I don't want to put people off from screening with this conversation. You know, if they're screening programs, it's reasonable for people to present themselves for that. 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. 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. 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? 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.

[A]

Yeah. So a watch and wait.

[B]

Exactly. Watchful waiting.

[A]

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. And so people would think, well, that's because, you know, we're just catching this stuff earlier, so the early screenings work. But that's not entirely what's going on. So what is going on?

[B]

Well, it's a little bit of mixture of things and it is kind of a hard thing to wrap your head around. Certainly people are surviving from, say, symptomatic cancers. So cancers that unequivocally need to be treated. People are surviving better because cancer treatments are better. You know, there used to be no treatment for melanoma. Now there is a treatment. So, you know, treatments for cancer are getting better. 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. So just imagine that you screen 1,000 people for cancer and let's say 100 of those were destined to get symptomatic cancer at some point in their lives. But you over diagnose 300 people and you treat all of those 300 people for cancer. Well, 200 of those 300 were never going to get symptomatic cancer in the first place. But if you now look at how successfully you treated those people, the results will look really optimistic. They were never going to get cancer. They therefore they didn't get cancer, and therefore they didn't die of cancer, but they were never going to. Anyway. I hope I'm making sense here because it's, it's, you know, if you over diagnose 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. 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. So you can look at one of two things. Did they die of cancer? Well, one would hope if you're over diagnosing cancer, that the answer to that question would be no. So let's look instead at this thing called all cause mortality. So deaths for any reason. 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 cancer. And they found that they had not prolonged any lives in most of the groups through cancer screening. 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. And the reason for that is if you're over diagnosing, so you screen people, you save somebody's life for sure. So you found somebody who had a cancer that was going to grow, you found it, you treated it, you saved that life. But probably there are 10 or 20 other people who you treated who never needed to be treated. And now you have negatively impacted the health of those 20 people. 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. So you're saving some lives, but you are having a very negative impact on others. So it's a kind of zero sum game, you know, yes, some people are saved, but other people are given unnecessary treatment that is dangerous to them.

[A]

Yeah, cancer treatment is rough.

[B]

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. And it's a very frightening thing. 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. But also the psychological impact of being told you have cancer is absolutely enormous. And then we've got the kind of financial impact in terms of insurance or jobs or applying for mortgages going forward. So there's. We've got a very kind of strong focus on saving that one life. And I think we have an unnecessarily kind of blase attitude to that over diagnosed group.

[A]

One area in cancer where you see a lot of over diagnosis due to screening. There's a lot of debate around it. Is prostate cancer? Why is prostate cancer so prone to over diagnosis?

[B]

Yeah, I mean, you know, so prostate cancer. It's because the type of screening they do for prostate cancer at the moment, now this will change and people are working on improving this. But at the moment, the most common type of screening is just to measure a blood test for prostatic specific antigen. 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. The problem with that test is it's just completely unreliable. You know, I draw people's attention to the fact that there is no national screening program for prostate cancer in the US or in the UK or in most countries in the world. And that's because this particular test has such a reputation for over diagnosis. You know, studies are really different on these statistics. But to give people a rough idea, if you screen 1,000 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. That's a lot of men who are now kind of going to go on a diagnosis. 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, a small number of them will have biopsies and a small number of them will be told that they do have prostate cancer. 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. 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 Prost. 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. So as men get older, they all get abnormal. A large number get abnormal cells in the prostate. And once you start screening for that using prostate specific antigen, you'll over diagnose lots and lots of men. So the unreliability of the test is the reason we don't do this. Now I think the solution to this is to screen the right people. So there are men who are at higher risk of prostate cancer than other people. People with family history of prostate Cancer. For example, black men are more likely to have prostate cancer. So you can still do screening, but screening is more meaningful if it's done in people who are at high risk, whereas if it's done in people with low risk, it can produce very unpredictable results. And also, if a person is really concerned about their health risk, they may still wish to discuss getting a PSA test with their doctor. But it's important they know before they have that test done how uncertain the interpretation of the results will be. Know yourself, in a sense, you know, are you the kind of person who, if they get that abnormal result back, will struggle to live with that knowledge? Or are you the sort of person who can enter a watchful waiting program and not worry too much? So it's all about knowledge, so you know what to ask and knowing whether you can handle the information that you get. Get back, Yeah.

[A]

I got an example of someone who had a deleterious outcome because of a PSA test. So he's in his 50s, got the PSA, it was elevated. And the doctor's like, I'd like to do a biopsy. And for those who don't know biopsies, they basically stick a needle through your rectum to your prostate and then extract some tissue. And he's like, I don't want to. No, I don't. I don't think so. I don't think I have prostate. I'm healthy, I don't have a history of it. And the doctor said, no, you need to do it. And so he. He did it and he ended up getting sepsis from the biopsy. And he was in the hospital for a few weeks. And he didn't end up having prostate cancer. There was nothing there.

[B]

Well, that's it precisely. 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. So they're working obviously very hard on proving this screening. And in the future, I hope that things will be better. But at the moment, there is no national screening program for a reason, and that's worth thinking about.

[A]

We're going to take a quick break for your word from our sponsors. You've probably seen ads for hair supplements and thought, yeah, sure, that actually works. I get it. I don't deal with hair thinning personally yet, but when I do, Nutrafol is where I'm going to start. Nutrafol is physician formulated, clinically tested, and recommended by dermatologists. What really sets it apart is that they don't just test ingredients individually. They test the actual final formula using real tools like hair counts and pull tests to assess thickness, texture, shedding and overall growth. And it's not complicated. You take four capsules a day with a meal and that's it. No prescription required. And they offer free shipping and automated delivery so you can stay on track. Plus, subscribers get access to free doctor consults and a Headspace Meditation membership, which is a nice bonus. See Thicker, stronger, faster growing hair with less shedding in just three to six months with NutraFol get $10 off your first month subscription and free shipping when you go to nutrafold.com and use promo code AOM that's n u t r a f o l.com nutrafol.com promo code AOM for $10 off your first month subscription & free shipping Hiring the right person isn't just about filling a role. It can make or break your team's momentum. And if you ever needed to hire fast, you know how quickly the process can turn into a time sucking mess. I know friends who could have used Indeed when they're trying to fill some key roles. It would have saved them a ton of time and frustration. When it comes to hiring, Indeed is all you need with Sponsored Jobs, your post goes right to the top of search results so you get in front of the right candidates faster. And it works. According to Indeed data, sponsored jobs posted directly on indeed get 45% more applications than non sponsored jobs. No monthly subscriptions, no long term contracts. You only pay for results. And while I've been talking, according to Indeed, 23 hires have already been made worldwide. There's no need to wait any longer. Speed up your hiring right now with Indeed. Listeners of this show. Get a $75 sponsored job credit at indeed.comaom Just go to indeed.comaom and support the show by saying you heard about it here. Indeed.comaom indeed.comaom terms and conditions apply. Hiring Indeed is all you need. As summer winds down and those cooler evenings start to roll in, I've been thinking about how to make the most of our backyard this fall. I recently went on Wayfair to check out their selection of fire pits, and I was surprised by how many great options they have. Whether you want something simple and functional or more of a statement piece, it's all there. There's just something about sitting around a fire with your family on a crisp evening. No phones, no screens, just talking and hanging out. That's why I'm trying to create more of this season. And Wayfair makes it easy to get what you need without spending a ton of time or money. Beyond fire pits, they've got everything. Grills, Adirondack chairs, lighting, outdoor rugs and more. And shipping. It's free even on the big stuff. Whether you're wrapping up summer or getting your space ready for fall, Wayfair is a one stop shop shop. Outdoor furniture, grills, long games and way more for way less. Head to Wayfair.com right now to explore a huge outdoor selection. That's Wayfair.com w a Y-F-A-I-R.com Wayfair Every style, every home. And now back to the show. You mentioned colon cancer and there's been more of a push in the past decade or so to get a colonoscopy. And I think the recommendation for the age to get your first one has been lowered. It used to be 50, now it's 45, at least here in America.

[B]

Yeah, we don't have colonoscopy as a standard screening tool. In most countries. It's usually testing for blood in your feces and if there's blood there, then that potentially is symptomatic cancer, but it could also be hemorrhoids. So that's the usual type of screening that it wouldn't be to go straight to colonoscopy. Because colonoscopies, you know, that's an unpleasant test that comes with risks of things like perforation. You don't want to leap into that unless you have a family history. Again, we're, we're, we're always back to this sort of. These things need to be made, these decisions need to be made in the context of risk. It's like, what's your clinical story? What's your story? What's your background? If you've got a family history of colon cancer, then you're in a high risk group and then certainly colonoscopy is something you'd want to consider. But if you're someone who's very healthy, with a very healthy diet, who is asymptomatic, then that may be not something you want to consider.

[A]

Yeah, that's something I've interesting. I've noticed America tends to be screening happy. We love our tests and not so much in Europe.

[B]

Yeah. Well, do you know what? We do fair bit of screening as well. But I, I think you're, you're right, we're not quite as. I think it's how, to a certain degree, it's how our health services differ. You Know, we in the National Health Service, in a way I, I consider myself to be protected by the NHS from over diagnosis because, you know, there's no, you can't have a test on demand. We're much less likely to have whole body MRI scans or to have MRI scans if you have no or minimal symptoms. And I'm quite happy with that turn of events because the more tests you have, the more likely you are to find these incidentaloma things. And I think that one really sobering study was in the New England Journal, I've forgotten the date of it now, but very, very recently, in the 2000s roughly. And they looked at cancer diagnosis in high income countries, like the U.S. for example, versus low income countries. And what they found was that yeah, people live longer in high income countries. Well, that's not surprising. You know, you, you don't only have better healthcare, you also have better lifestyles, et cetera. But they found something else that is worrying. They found that much more people were being diagnosed with cancer in the high income countries than in the low income countries. But the cancer survival rates for those cancers were actually quite similar. So it's, 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. No extra lives were saved by all the extra cancers being diagnosed. The paper estimated that, you know, for every cancer diagnosis through all of this availability of technology, 10 probably weren't necessary. So, you know, I, I know that the NHS has a great deal of problems, it needs to be a lot better funded than it is. But there is something to be said for the lack of financial dealings between patient and doctor. You know, a patient comes to see me, the diagnosis is dependent on nothing but the story that they tell me. I have no, they are not my customer, I don't need them to come back to me to be paid and so forth. And there's something in this kind of financial transaction between patient and doctor that is, is potentially harmful. And I don't think people always realize that.

[A]

Another area you talked about where there could be some over diagnosis going on is diabetes. That's because the diagnostic boundaries have shifted in the past, I think, decade. What was that change and how has that led to over diagnosis?

[B]

Yeah, so this is a trend in medicine in multiple different areas of medicine. So you, you know, there's lots of medical problems which the diagnosis isn't based on there being an abnormality, it's based on drawing a line between normal and Abnormal, like, what level of blood sugar are we willing to accept as normal? What level of blood pressure are we willing to accept as normal? 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, borderline obesity, borderline mental health problems, that we will help more people. And therefore we keep adjusting the line between normal and abnormal to diagnose more and more people. So I think it was in about 2003, we had created this condition called pre diabetes. So this isn't diabetes. This is a kind of borderline state between being perfectly healthy and potentially going on to develop diabetes. But in 2003, they made this slight adjustment to the measure that would allow a diagnosis of prediabetes and a fasting blood glucose. You fast, you have your blood sugar taken, and on one day in 2003, if you had a measure of 6.1 millimoles per liter of fasting blood glucose, you were healthy. But then they adjusted that and said, no, 5.6 will be the new cutoff. So it's just a small change. You know, one day 6.1 is normal, the next day 5.6 is normal. 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, this small adjustment, along with some other changes in how the diagnosis was made, would mean that half of Chinese adults would be pre diabetic and a third of us adults would be pre diabetic. So, kind of you're sitting at home minding your own business, essentially, and you feel you're perfectly healthy. And meanwhile, somewhere in the background, a committee is convened and deciding, you know, what, what counts as normal glucose. And on a Monday, they change it. And suddenly you are no longer healthy. Now you are a patient. And this is done with very good intention. It's because, well, now we've recognized loads of more people with pre diabetes. We can stop people getting diabetes. The problem is that it's not working. The rates of diabetes are rising all the time, Even though for 20 years we've had escalating diagnoses of pre diabetes. And this is really the absolute definition of over diagnosis, is you identify more and more and more patients, but you're not actually making people healthier. And it may be that they're not following the advice that they were given, for example, but what is clear is that this kind of growing group of people with pre diabetes is, is not benefiting them to know that yeah.

[A]

And what's interesting about pre diabetes, it's in this weird gray area because it's not officially a diagnosis, but then people treat it like a diagnosis. They think of themselves as a patient. Well, I have pre diabetes and I have to do certain things to make sure I don't get full blown diabetes.

[B]

Yeah, that's it. It's a weird sort of like it's not actually a disease, pre diabetes, it's like a pre disease state. But it sounds very much like a diagnosis and in one sense it could be a great thing. So it depends really on your mindset and your lifestyle and how you respond to news. 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. And, you know, it could have a really positive impact on me. It could be a really good thing for my long term health. But somebody else might respond differently to that. 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. It can affect. If you turn a person into a patient, they can start behaving like a patient. They begin noticing things about their body. You know, being told that you're unhealthy turns your attention inwards to your body. And then you start noticing little things and worrying about symptoms you didn't worry about before. You know, in a sense, the creation of prediabetes, we created it to protect people's long term health. But we've underestimated the impact of the news that you have prediabetes 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.

[A]

It threw me for a loop for a while. So I remember I had some blood work done and my fasting glucose was high, it was like 102. And I was like, oh my gosh, I got pre diabetes. And I, I even went out, I bought a glucose monitor, started measuring my glucose every day. And I'm like, I don't know what I'm supposed to do because I exercise, I eat right, I don't drink, I'm doing everything, I'm not overweight. And I remember finally talked to a doctor, I was like, what do I do? I have pre diabetes. And they're like, well, let's check your insulin. Your fasting insulin looks good. So you don't look like you're on the road to diabetes. Maybe your glucose Just runs a little high in the morning. And that's your normal.

[B]

Yeah, well, that's it. You know, again, I kind of remind people of how different we are on the outside. And, you know, these sort of differences exist on the inside too, and it doesn't have to be an abnormality. And in a sense, you made the important point there, which is you are otherwise a very healthy person. You know, these things have to be taken in context. 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. 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. So we need to take these things in context and, and not be terrified of every abnormal result.

[A]

You mentioned high blood pressure has undergone a change similar to diabetes and how we define it.

[B]

Yeah, I mean, you know, so there's this thing sort of borderline hypertension, which I guess is the same as pre diabetes. You know, your blood pressure is kind of in that border area. You're not really hypertensive, but you, you could spill over into that region. The level of blood pressure required to have borderline hypertension just keeps shifting. And in the US now, borderline hypertension is a measure of 130 over 80. Now, when I was in medical school in the 1980s, 130 over 80, you'd be delighted with that blood pressure. That's perfectly normal blood pressure. 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. In Europe, we use a slightly more generous cutoff, more around 140, 80 or 140 over 90. Because these are arbitrary cutoffs. No one knows where normal blood pressure begins and ends. So committees of experts get together and make arbitrary cutoffs. 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 borderline hypertensive, which is just astonishing statistics. Can it really be true that a third of adults in the US are borderline hypertensive? The purpose is good. The purpose is prevent heart disease, prevent strokes. But how many people with borderline hypertension do you have to treat to prevent a stroke? Well, that could be. If I treat every single person I meet with borderline hypertension, I might Prevent, you know, one stroke per thousand people, but I might treat 150 people who never needed to be treated. So you always, with these adjustments, you're always saving somebody. But equally you can be guaranteed you're over treating a great deal, many more people. So you probably, you know, per life save, you're probably over treating 100 and 150 people. But that's, you know, that's okay if it's just a little kind of reminder to be healthy. 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 and I don't object to that. 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. So we have to think of both sides of it.

[A]

Another area you talk about where there's a lot of over diagnosis is Lyme disease. Why is Lyme disease so hard to diagnose and why is it vulnerable to over diagnosis?

[B]

Do you know what the first thing I'd say is? I don't think Lyme disease is hard to diagnose. Lyme disease is very well defined clinical criteria and you know, no test is 100% reliable, of course, but pretty reliable. You two stage blood testing, there's two stages of blood testing. You have to make the diagnosis. So actually I'd say diagnosing Lyme disease is relatively straightforward. The reason it's so over diagnosed is twofold. 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, you know, just these kind of non specific symptoms that are part of loads and loads of different medical problems, including psychiatric problems, but also physical problems and also aging. So these are super common symptoms. So that makes Lyme disease very available to over diagnosis. 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. That's one reason I think it's over diagnosed. It's in a world where people are suffering and want answers. It's an answer. The other reason it's over diagnosed is because the tests are misused. Really? You know, as I've said before, tests need to be taken in a context. The tests for Lyme disease have lots of reasons. You can have a positive test but not have Lyme disease. 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. And later in life, if you have a blood test, you can test positive for Lyme but not have Lyme disease. Or maybe if you're sick in some other way, you'll get a false positive on the test. So the tests are easily misinterpreted. And you've got a disease that has symptoms that overlap with so many other things. And you've got a society that needs explanations when they're not feeling well. And if explanations aren't readily available, then Lyme disease will account for quite a wide range of symptoms. Then you also have an element of corruption added in here. 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, then over diagnosing is very, very simple because of the uncertainties in the blood test.

[A]

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, but Lyme disease, the bacteria that causes Lyme disease, doesn't exist in Australia.

[B]

Yeah, I mean, this really speaks to the problem. So you know exactly that. I mean, the, the type of, the climate in Australia, the type of ticks that carry the bacteria that cause Lyme disease, they can't survive in Australia because of the climate, and therefore nobody has found the bacteria in any ticks that live in Australia. And yet there's something like a half a million people in Australia who believe they contracted Lyme disease in Australia, which is fundamentally impossible. And yet people are getting these diagnoses. But, you know, there's similar very high misdiagnosis rates in the US So a specialist Lyme disease clinic reviewed the diagnosis of a large thousands. I think it was 5,000 people who had a diagnosis of Lyme disease went to this specialist Lyme disease clinic and they determined that 85% of the people who thought they had Lyme disease did not have Lyme disease. So this is a diagnosis that is overused at an enormous Rate. It's estimated that about 60,000 people test positive in a proper lab that is making the diagnosis correctly in the U.S. 60,000 people per year. And yet something in the region of half a million people are being treated for Lyme disease. So. So the number of people being overdiagnosed is very high. And I think that's because it's an available explanation for symptoms that people struggle to explain. And I think it's also because there is a problem with people essentially giving out slightly over exuberant diagnoses for monetary reasons.

[A]

What do you think's going on with these people who, you know, they get the diagnosis of Lyme disease, but maybe they don't have it. 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. But they're obviously suffering. You know, they've got the fatigue, the joint pain, brain fog. Similar thing happened with people after Covid. You're like, I got, you know, this whole idea of long Covid. They're obviously suffering. So what do you think's going on?

[B]

Yeah, I think, I mean, that's a super important point to emphasize, which you just did, which is to say that someone has been misdiagnosed doesn't mean they're not suffering. But yes. So there's, at any one point in time, there's a lot of people who are suffering with non specific symptoms like headaches, difficulty sleeping, joint pains, tiredness. And those people will be given a diagnosis that sort of makes sense at a particular point in time. And as you said, during a COVID pandemic, if you have that collection of symptoms, you'll be could be told you have Covid or long Covid. You know, if you live beside a forest filled with Lyme disease or in a period when Lyme disease is common, you can be given Lyme disease as a diagnosis for the exact same symptoms. What is going on with these people? Well, there's a variety. People are probably just hard to diagnose. They have something that we have not yet fully understood, like an autoimmune condition that we don't yet fully understand. But I would suspect that the largest proportion of these people probably have what I would refer to as psychosomatic symptoms. So I'm a neurologist. This would be something I would see very often. So a lot of people, in response to stresses or anxiety or difficult lives or unhealthy lives, develop non specific symptoms. So we've all had this experience. You Know, if you're stressed, you get a headache, 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. So our bodies are very vulnerable to developing physical symptoms in response to psychological stressors. And very common symptoms in that context are things like tiredness and aches and pains. I actually see people with much more extreme versions of this, with seizures, paralysis, blindness and so forth. I think a great many of these people have psychosomatic symptoms, but we live in a society that looks down on psychosomatic symptoms. 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, and you learn that the problem has a more of a psychological cause than a physical cause that's looked down on. You know, we don't have a lot of respect for that. And that pushes people into the need to find an explanation that society is more understanding of. And usually that's a physical disease. So I think there's a lot of people who have an array of physical symptoms that probably arise out of psychological distress, but which are diagnosed as a disease because that's the culture we live in. You know, psychological suffering is not respected to the same degree as physical disease.

[A]

And you talk about once someone gets a diet like a medical, a biological diagnosis for what could be psychosomatic, it causes the nocebo effect, where you start paying more attention to your body and thinking, oh, this is actually. This shows that I have this thing and it just sort of creates this vicious cycle downwards.

[B]

Yeah, I mean, this is the problem with all the medical labels we've been talking about. This is the problem for the people with hypertension, the people with pre diabetes, the people with cancer, et cetera, is that once you're given a medical diagnosis, it can have, you know, it's. Everyone's familiar with the placebo effect, which is if you given a tablet and you believe it will work, it can alleviate your symptoms. The exact same happens in the opposite direction, referred to as the nocebo effect. So this is where, you know, if you believe something will make you sick, it can make you sick. I always say to people, listen, there is examples of this in everyday life everywhere. 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, it would immediately changes your experience of your body following what you've just eaten. You know, if you eat something and then you suspect it was unhygienic after the fact that you can start feeling sick. This is the most normal thing in the world. So imagine now that somebody has told you that you have a disease and that it causes, you know, X number of symptoms, you immediately kind of look at your body and begin examining yourself for those symptoms. And I guarantee you, especially as you get older, your body is awash with things to be found if you pay enough attention. You know that aching knee that you know it only lasted a day, normally you dismiss it, but you've just been told you have Lyme disease. So now you place a lot of emphasis on that aching knee. Whereas you might not have worried about it yesterday, or, you know, some little mole on your skin suddenly gets heightened in your perspective through anxious attention. This is the problem with medical labeling, 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, when really worrying less about your health is sometimes the answer.

[A]

There's been an increase in mental health diagnoses in the past few decades. Are there actually rising rates of mental health issues or are we diagnosing people that maybe don't need a diagnosis?

[B]

Yeah, so it's such a super harsh question answer in the sense that it's so hard to untangle. You know, in. 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, there does appear to be more mental health issues in this group, for example, more than any other. And that means they're more likely to go to their doctor with symptoms and also that they have more mental health symptoms. But does that mean that there is more mental health illness in this group? Because that can be explained in so many ways. 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. 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. Are they more symptomatic because of the anxious attention that they're paying to their moods, or are they genuinely more symptomatic? So I think it's really hard to untangle. To what degree is the fact that young people have more mental health problems there? 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? 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. 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. That's not my attitude. 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. The reason I say there's over diagnosis is very hard to spot over diagnosing individuals. 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. Is that over diagnosis or isn't it? You can't really tell, but you can tell by looking at the population. So we've been making mental health diagnosis at escalating rates since the 1990s. We've been telling young people they have ADHD and autism at escalating rates since the 1990s. Now, the purpose of seeking out those young people and giving them those labels is that their problem should be recognized, they should get support, and then they should be happier, healthier, better adjusted adults. But what do we see downstream? 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. And that's the very definition of over diagnosis is 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. And we really need to rethink what we're doing. You know, 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, then you potentially make that problem so concrete that a child can't overcome it. Adolescence is a time of change. You should have the opportunity to mature out of your difficulties or to work on things. 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.

[A]

People get really touchy about this, particularly around ADHD and autism. I know it can get very heated, the debates about it. Why do you think that is?

[B]

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. And that's certainly not how I feel about it. I think that adolescence in particular is a real time of difficulty, but also people who are getting diagnosis in older age. I believe the difficulties are real, but I don't think medicalizing the difficulties with these labels is the right thing to do. 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 or, you know, I was in school in the 80s, you know, nobody in my class of 120 was recognized as having a special learning need. There must have been someone, you know. So we had an underdiagnosis. This problem. 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. You know, is. Is it really optimal? 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. But is then attaching a medical label the right way to go about things? And I know that it can make people feel validated, and I don't want to take that away from people, but I think that a diagnosis needs to come with something more than validation. It needs really to lead to something more positive. Unfortunately, when you're validated by a diagnosis, it can just make the symptoms worse. 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. Getting well means you lose your tribe and you potentially lose your diagnosis. So how do you get well in those circumstances? 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.

[A]

And in the case of adhd, I mean, one of the things you do to treat it is, you know, prescribe Ritalin or Adderall, which, I mean, those are Schedule 1 substances. Like, those can be highly addictive substances. It's like, well, maybe you don't need to get on that if you don't need it.

[B]

Do you know it's interesting how badly we learn from the past. We had a whole benzodiazepine crisis in the 80s. It seemed to be a drug that did amazing things for people. But then people got highly addicted to it and then we had an opioid crisis. For a while, everyone thought opioids were the best thing ever and look where that led us. We're not very good at learning from the difficulties of the past. 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 now. That's not to say that I don't think there's a role for medication. There will always be people who have extreme disability. There always are hyperactive children who are so hyperactive they really cannot engage in education and they may need something to help them through a difficult period. So I'm not a kind of never say never, but this wide prescribing of stimulant drugs seems really ill advised to me.

[A]

So what do you think the right balance is between diagnosing too much and not diagnosing enough? Like, what do you want readers to take away from your book the next time they're dealing with a health concern?

[B]

Yeah, so I think what's really important is, first of all, you know that you have choices very often, and I think that's something people don't really realize. Most medical situations are not urgent, 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. 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. Are you a high risk person? What else in your life might put you at risk of this particular disease 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. 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. You know, a lot of neurologists wouldn't have a brain scan as it happens. 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. I really want people to just do a balancing exercise when it comes to diagnosis. Ask themselves before they get that that mental health diagnosis or ADHD or autism diagnosis. If I get this diagnosis, what will I get? What will it bring me that is positive? And if I get this diagnosis, what are the potential negative impacts of that diagnosis? And you really need to be sure that what you get is substantially greater than what you lose through diagnosis.

[A]

Well, Suzanne, this has been a great conversation. Where can people go to learn more about the book and your work?

[B]

Well, I hope everybody will buy the book, which is called the Age of How Our Obsession with Medicine is Making Us Sicker. 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? But actually, everything I'm talking about is widely discussed within medicine. We're just not having a good enough public conversation yet.

[A]

Well, Susanna Sullivan, thanks for ty. It's been a pleasure.

[B]

Thank you for having me.

[A]

My guest here is Dr. Susannah Sullivan. She's the author of the book the Age of Diagnosis. It's available on Amazon.com and bookstores everywhere. Check out our shownotes at AOM is Diagnosis, where you can find links to resources where we delve deeper into this topic. Well, that wraps up another edition of the AOM podcast. Make sure to check out our website at artofman where you find our podcast archives. And while you're there, sign up for our newsletter. We have a daily and weekly option. They're both free. It's the best way to stay on top of what's going on at aom. And if you haven't done so already, I'd appreciate it if you take one minute to use your normal podcast or Spotify. It helps out a lot. And if you've done that already, thank you. Please consider sharing the show with a friend or family member. You think of something out of it. As always, thank you for the continued support. Until next time, is Brett McKay remind. Listen anyone? Podcast would put what you've heard into action.

[B]

Action.

[A]

The world is full of tours, but you don't choose a Toyota truck to follow the beaten path. You choose it to find the detours where each adventure pulls you toward the next. And wrong turns turn out right. Toyota trucks.