When doctors make people sick

This morning a UT reader wrote in to ask, Is High Cholesterol a hoax?

Eye-catching subject line!

In fact, she wasn’t being conspiratorial. She wasn’t really asking if cholesterol didn’t exist. She was responding to an apparent epidemic of statin overtreatment in basically healthy women she knows.

Her note hit me hard, in part because of my depressing primary care visit in January (I have not returned to that doctor, or any doctor, since).

Our system pushes everything from testosterone to painkillers to antidepressants to statins on everyone it touches. Drug companies spend tens of billions of dollars a year to generate demand. Wearable devices give people the chance to rate their sleep and catch cardiac problems they might never have noticed. Electronic medical records and the massive consolidation of healthcare result in algorithms that force doctors to treat charts rather than patients.

The system now normalizes sickness — at a psychic cost that almost no one realizes.

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(Exposing the real costs of medicine. With your help.)

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We need to talk much more about what we’re doing to medicine, and what it’s doing back to us. I know you agree - January’s piece got massive feedback.

So here’s another brick in that wall. Her (unedited) email is below. My response follows. Please feel free to add your thoughts.

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I’ve followed your work since the early days of Covid, and I guess this is my first opportunity to thank you for keeping me somewhat sane during those days. Truly, I thought I was the crazy one in a locked-in, masked-up, and vaxxed-out Chicago until my mom introduced me to your Twitter feed. (She’s followed your work even longer, having read “Tell Your Children” and even some of your spy novels - what a range!)

I’ve also really appreciated your honesty around all things Big Bad Pharma and your exposure of the broken medical industrial complex (I live in Indiana where those scam autism day care rackets are happening!). So I wonder if you could shed light on a phenomenon that may have been happening for a long time but suddenly seems to be occurring more often and closer to home than I’d experienced until now: the high cholesterol scare.

In recent months, I’ve had several middle-aged (50s and 60s - the new 40!) female family members, coworkers, friends share that their doctors have been telling them their cholesterol is way too high, they’re in danger of becoming diabetic, they need to be on statins and lay off all foods except plain chicken breasts (okay, and some beans too) or they’re putting themselves at risk of imminent stroke, etc, etc.

These women are all in good shape, not overweight at all and, in some cases, eating pretty healthy diets already. What’s going on here? Am I suddenly on the alert only because, as I mentioned, it seems to be affecting me personally? Or is there some kind of new push by Lipitor et al to capitalize on the Baby Boomers while they’re still with us?

Mind you, I don’t fail to suspect that factory farming and overall bad American lifestyles have something to do with this too. But I think the true scientist in me has to ask the questions and sometimes you just need to follow the money.

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(First, make sure you have completed the patient’s DRG codes so we can properly bill…)

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My answer:

This is a good question (I’m answering quickly because I may use this for a piece, and I want to get my thoughts down right away). I think what’s happened with high cholesterol is what’s happened with high blood pressure.

That is, we have very good evidence that both high LDL/triglycerides and high blood pressure are dangerous. They lead to artery blockages, hardened arteries, heart attacks, strokes, premature deaths. Particularly in people who have already suffered a heart attack, lowering cholesterol and blood pressure can be life-saving.

The question is what to do with people who have moderate or moderately high blood pressure or cholesterol, particularly when those people are over 50 and are having the normal increases that result from aging. Most adults are NOT going to be willing to make massive changes in their diets or exercise (whatever their baseline health/exercise level), no matter what doctors tell them.

So what do you do with a 55-year-old woman who has never had heart problems and has an LDL [low-density lipoprotein, aka “bad” cholesterol] of, I don’t know, 150 and a BMI [body mass index] of 23 - 5’6” and 145 pounds? Doctors are increasingly incentivized to push statins on her, even though 10 years of statin therapy might reduce the risk she is going to suffer a heart attack over that time from 1.5% to 1.2% (again, I’m guessing, but that figure is available, and I’m basically in the ballpark). The absolute risk reduction is tiny, but the RELATIVE risk reduction is 20 percent over the decade.

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This is me asking for a one-time donation! Don’t make me beg! (Okay, I guess I’m begging already.)

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Does this make sense? Statins are pretty cheap right now, so the cost isn’t really an issue. And most people don’t have terrible side effects from statins, though some have bad muscle weakness (in that case a decent doctor would discontinue treatment for this woman).

But I think two questions should be asked. The first is medical and asked less than it should be, the second philosophical - and basically NEVER asked, though it should be.

The first: is this level of risk reduction worth even modest side effects?

The second: is it worth making this basically healthy woman think of herself as sick - someone who needs treatment because she is at risk of a heart attack? In a famous 1978 essay called “Illness as Metaphor,” Susan Sontag wrote of the “kingdom of the well” and the “kingdom of the sick,” adding “although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”

Except I don’t think that’s really true anymore.

I think that in the modern medical system, particularly in the United States, both doctors and the people they care for have become much too comfortable spending most of their time in the kingdom of the sick. I think we see this trend in basically every field in medicine, in patients from infants to the elderly. Drug companies fuel it, of course, but they are not solely responsible.

People are better off when they think of themselves as basically healthy, rather than sick. This seems obvious to me, and yet medicine’s every incentive points the other way, and the bureaucratization of medicine has without any doubt worsened the problem.

What to do?

I don’t know, and I have gone far afield from your question. Maybe UT readers will have ideas...

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January’s piece: