Book Review

Disease-Mongers: How Doctors, Drug Companies, and Insurers Are Making You Feel Sick

N Engl J Med 1993; 328:218January 21, 1993

Article

Disease-Mongers: How Doctors, Drug Companies, and Insurers Are Making You Feel Sick
By Lynn Payer. 292 pp. New York, John Wiley, 1992. $22.95. ISBN: 0-471-54385-3

The worried well present a treatment dilemma in our technology-oriented medical system. Lynn Payer, author of Disease-Mongers, accuses “doctors, drug companies, and insurers” of exploiting patients' fears for financial profit. Her book, aimed at a lay audience, exposes what she calls “disease-mongering,” the process of convincing people who are well, or at least asymptomatic, that they require medical attention. Her chapter titles are a litany of indictments: “The Medicalization of Menopause,” “The Diseasing of Risk Factors,” “Creating Cardiac Cripples.” Although she admits that medical journalists and even patients themselves have a role in this process, her subtitle reveals her bias.

Payer is at her best when she documents the insidious ways health awareness turns to disease in the mind of the patient. She asks us to weigh the benefits of lowering moderately elevated cholesterol levels against the psychological impact of labeling patients as being at risk for heart disease. She has a keen eye for the statistical trap, citing the manipulation of statistics to overemphasize risk, like the “one in nine” lifetime chance of having breast cancer that needlessly frightens women who are at much lower risk in any given year. Payer demonstrates how journalists frequently combine prevalence figures based on the broadest definition of a condition (like echocardiographic evidence of mitral-valve prolapse) with morbidity and mortality data for a severely affected subgroup (patients with severe mitral regurgitation) in order to capture headlines.

On the other hand, in her zeal to create a villain, Payer occasionally loses credibility. For instance, she asserts that physicians “medicalize” everyday fatigue to create chronic fatigue syndrome. She substantially underplays the role of patient-advocacy groups and the media in promoting this disease. Blithely ignoring the problems of secondary gain, disability certification, and chronic depression, she suggests that physicians follow the advice of Dr. Richard Huhn and tell patients, “There is not always an explanation and there is not always a solution: The patient must be made to understand this, and then he or she must accept the situation as best as possible and, perhaps, laugh at it.” Throughout the book, she also assumes that all physicians are working in a fee-for-service setting, where they will personally benefit financially from ordering a given test or procedure. Even in private practice, that is frequently not the case, and in the health maintenance organization the reverse may be true.

Payer is a good journalist and an entertaining writer. The subject of the overmedicalization of our society is critical, particularly as the debate about controlling medical costs heats up. Payer is right: we in the health care professions should recognize our role in promoting medical intervention for problems in living and elevating risk factors to the level of disease. But it takes two to tango. Plastic surgeons could not convince women to have breast implants if they felt secure about their self-image. If patients were not so entranced with the illusion of a technological fix for anxiety, the pharmaceutical companies would not profit so handsomely. As Payer, who is also author of Medicine and Culture (New York: Henry Holt, 1988), knows well, physicians reflect the values of the culture they serve.

Toni Martin, M.D.
235 West MacArthur Blvd., Oakland, CA 94611