When Prevention Becomes Its Own Disease

This article explores how anxiety about health screening numbers can lead to overdiagnosis and unnecessary treatment that may cause more harm than the conditions we're trying to prevent.

I keep a small notebook in my bag where I jot down blood pressure readings from house calls. Not the formal chart ones - those go in the records - but the second readings. The ones after we've talked for twenty minutes about their garden or their grandson's wedding or the leak in the bathroom ceiling.

Preventive Screening Tests: Benefits vs. Psychological Burden

Screening Test	What It Detects	Clinical Benefit	Potential Psychological Impact
Coronary Calcium Score	Calcium deposits in heart arteries; scores >400 indicate highest risk	Identifies silent heart disease; guides statin therapy decisions	May cause cardiac anxiety, hypervigilance about chest sensations, avoidance of physical activity despite being asymptomatic
BRCA Genetic Testing	Gene mutations increasing breast/ovarian cancer risk	Enables early surveillance or preventive surgery in high-risk individuals	Can create persistent cancer worry; impacts family planning decisions; potential for genetic discrimination concerns
Alzheimer's Biomarker Panel	Brain proteins (amyloid, tau) indicating dementia risk decades before symptoms	May allow early intervention when treatments become available	Creates anticipatory grief; may alter life decisions based on probabilistic future; limited treatment options currently available
Home Blood Pressure Monitoring	Daily BP variations; white coat hypertension vs. sustained elevation	Improves BP control; helps titrate medications accurately	Can lead to obsessive checking; anxiety-induced readings; hypervigilance about normal fluctuations
HbA1c Screening	3-month average blood sugar; prediabetes and diabetes detection	Enables early lifestyle intervention; prevents complications	May create food anxiety; constant metabolic self-monitoring; identity shift to "pre-diabetic"
Low-Dose Chest CT	Early-stage lung cancer in current/former smokers	Reduces lung cancer mortality by 20% in high-risk groups	False positives common; anxiety during nodule surveillance; radiation exposure concerns

The first reading is almost always higher. Sometimes dramatically so. 160/95 becomes 135/80. 145/90 becomes 128/78. I used to think this was just "white coat syndrome" - the clinical term for anxiety-induced blood pressure spikes in medical settings - until I noticed something odd. The phenomenon persists even when I'm sitting at someone's kitchen table, even when we've known each other for years, even when there's no white coat in sight.

What I'm seeing isn't fear of doctors. It's fear of diagnosis.

The Paradox of Modern Screening

Here's what happened to anticipatory medicine in the decade since we started using it widely: it worked. And then it worked too well. And then it started creating problems we didn't fully anticipate.

Mr. K.H., seventy-two, came to me after his cardiologist ordered a coronary calcium score - a CT scan that quantifies calcium deposits in coronary arteries, used to assess heart disease risk. His score was 438. For context, anything over 400 puts you in the highest risk category for future cardiac events. His cardiologist started him on high-dose rosuvastatin, a potent cholesterol-lowering medication, and aspirin. Textbook management.

But when I saw him three months later, something had shifted. He'd stopped walking his usual morning route because "what's the point of exercise when my arteries are this bad?" He was checking his pulse constantly. Obsessively, really. He'd wake at night wondering if the mild indigestion he felt was actually angina - chest pain from insufficient blood flow to the heart muscle.

The scan had found disease. Real disease. The treatment was appropriate. But in finding it, we'd also found - or perhaps created - something else: a person who now lived in perpetual fear of their own cardiovascular system.

I don't think his cardiologist did anything wrong. I wouldn't have managed it differently. But I keep wondering if we've fully reckoned with what it means to tell someone, "You have significant disease, but you feel fine, and we're treating you so you continue to feel fine."

The Cognitive Load of Being At-Risk

There's a term in psychology I've been thinking about lately: allostatic load. It refers to the cumulative wear and tear on the body from chronic stress. The term was coined by Bruce McEwen and Eliot Stellar in 1993, and it captures something crucial about how our stress response systems - hormonal, immune, metabolic - can become dysregulated from sustained activation.

What we're seeing now, increasingly, is a kind of diagnostic allostatic load. The psychological burden of knowing you're at risk, even when you feel perfectly well.

Consider the trajectory of a typical person in 2025 who engages with preventive medicine: They get a coronary calcium score at fifty-five. Maybe a genetic test for BRCA mutations - alterations in specific genes that dramatically increase breast and ovarian cancer risk - or an Alzheimer's biomarker panel measuring proteins in blood or cerebrospinal fluid that suggest brain pathology decades before symptoms. They track their HbA1c - a three-month average of blood sugar levels, critical for diabetes screening - every six months. They monitor their blood pressure at home. They get colonoscopies, mammograms, low-dose chest CTs for lung cancer screening if they smoked, annual skin checks for melanoma.

Each test is evidence-based. Each offers genuine benefit. But cumulatively, they create a life organized around disease surveillance. And for some people - maybe more people than we'd like to admit - that surveillance becomes its own form of suffering.

I'm not suggesting we stop screening. Mrs. L.R. from the previous piece had minimal medical engagement precisely because she never needed it. But Mr. R.P.? He needed every intervention. The question isn't whether to screen. It's how to screen without turning the act of prevention into a chronic stressor.

When The Map Becomes The Territory

There's a conversation I have repeatedly with people in their sixties and seventies. It usually starts with them asking, "Should I get tested for X?" Where X is some genetic marker, some imaging study, some panel that promises to reveal hidden disease.

My answer has become more complicated over time.

A decade ago, I would have said: Yes, if the test changes management. If finding something early means we can treat it early, screen. Simple calculus.

Now I ask a different set of questions:
- If we find something, will you be able to live with the knowledge without it consuming you?
- Can you distinguish between statistical risk and personal destiny?
- Will this test give you peace of mind, or will it give you a new source of anxiety?

I'm increasingly aware that these aren't medical questions. They're philosophical ones. And we've been asking patients to navigate them without much guidance.

Consider atrial fibrillation. It's an irregular heart rhythm that significantly increases stroke risk - about five times higher than normal, varying with other risk factors. Modern smartwatches can detect it. Should everyone over sixty wear one? From a purely outcome-based perspective, yes. Early detection allows for anticoagulation - blood-thinning medication - which reduces stroke risk by roughly 65%.

But here's what I've noticed: some people find their Apple Watch reassuring. Others become hypervigilant. They check it constantly. They feel every irregular beat - or think they do - and spiral into panic. The watch, designed to catch rare dangerous rhythms, instead captures every benign variation in heart rate and turns it into a potential catastrophe in the wearer's mind.

The technology works. The medicine works. But the human being wearing it? That's where things get complicated.

The Unintended Consequences of Precision

I think about this whenever I see someone for lipid management - the careful regulation of cholesterol and triglycerides to prevent cardiovascular disease. We have extraordinary medications now. PCSK9 inhibitors can drop LDL cholesterol - the "bad cholesterol" that builds up in arteries - to levels we couldn't achieve a decade ago. We can measure apolipoprotein B, a more precise marker of atherogenic particles than standard LDL, and tailor therapy accordingly.

But precision medicine has introduced a new problem: the gap between what we can measure and what we can meaningfully act upon.

Take Lp(a) - lipoprotein(a), an inherited form of cholesterol that significantly increases cardiovascular risk but currently has no proven treatment. We can measure it. We can tell you if yours is high. We can quantify your increased risk. But we can't lower it reliably. Not yet.

So what do we do with that information?

I've had this conversation with three people this month. All had elevated Lp(a). All asked the same question: "What now?" And the answer - intensify other risk factors, optimize blood pressure and standard cholesterol, maintain healthy lifestyle - is the same as what we'd do if we didn't know their Lp(a) level.

Except now they know. They carry this piece of information that tells them they're at higher risk, and there's nothing specific to be done about it. Some find that liberating - at least they know. Others find it maddening. One woman told me, "I feel like I've been handed a genetic time bomb with no way to disarm it."

I didn't know how to respond to that. Because in a sense, she's right.

What Two 98-Year-Olds Can't Tell Us

I return often to Mrs. L.R. and Mr. R.P. because they represent two extremes of the aging spectrum. But here's what troubles me: neither of their stories offers much guidance for the messy middle - the vast majority of people who aren't cruising through their nineties untouched and who don't have severe disease requiring constant intervention.

Most people exist in a state of probabilistic risk. They have some calcium in their coronaries, some borderline lab values, some family history of something. They're not sick, but they're not guaranteed to stay well. And increasingly, we're medicating that uncertainty.

Not with pills, necessarily. With surveillance. With monitoring. With the constant background hum of risk assessment.

I wonder sometimes if we've mistaken information for control. We can sequence genomes, measure biomarkers, predict risks with increasing precision. But we can't predict randomness. We can't control stochasticity. And I'm not sure we've been honest with people about that limitation.

Mrs. L.R. won a genetic lottery she didn't know existed. Mr. R.P. lost one but was saved by medical intervention. Both stories are true. Neither is replicable by choice.

The Question We're Not Asking

Here's what keeps me up some nights: Are we creating a generation of people who feel chronically at risk, even when they're objectively healthy?

I see this in the rise of health anxiety - previously called hypochondriasis, now termed illness anxiety disorder - but that clinical label doesn't quite capture what I'm describing. I'm talking about rational people who engage appropriately with preventive medicine but find themselves burdened by the knowledge it produces.

Take prostate cancer screening with PSA - prostate-specific antigen, a protein that can indicate prostate problems but isn't specific for cancer. The evidence is nuanced. PSA screening reduces prostate cancer mortality by about 20% but also leads to overdiagnosis - finding cancers that would never cause problems - and overtreatment, with significant side effects. Current guidelines recommend informed decision-making rather than universal screening.

But what does "informed decision-making" look like in practice? I can give someone the statistics. I can explain the trade-offs. I can tell them that if we screen 1,000 men, we prevent one prostate cancer death but cause 20-30 cases of erectile dysfunction or incontinence from unnecessary treatment.

What I can't tell them is whether they'll be the one prevented death or the twenty harmed by overtreatment. And that uncertainty - that irreducible uncertainty - is what people struggle with most.

Living With Schrödinger's Disease

There's a thought experiment in quantum mechanics about a cat in a box that's simultaneously alive and dead until you open the box and observe it. I think about this sometimes when discussing screening tests.

Before the test, you're simultaneously healthy and diseased. The scan or blood draw collapses that probability wave into reality. But unlike Schrödinger's cat, which was always either alive or dead regardless of observation, some of what we find through screening exists in a genuinely ambiguous state.

Is a 3mm lung nodule cancer or scar tissue? We follow it for two years to find out. During those two years, what are you?

Is mildly elevated calcium in your coronaries a harbinger of a heart attack or just age-related changes that will never cause problems? The statistics give probabilities, not certainties.

Is your genetic variant for late-onset Alzheimer's a guarantee of cognitive decline or just a slight increase in background risk? We won't know for decades.

Modern medicine has given us the ability to peer into these quantum states of health, but we haven't developed a good framework for living in that uncertainty.

The Unspoken Cost

I had coffee last week with a colleague who works in preventive cardiology. We were discussing the explosion of imaging - cardiac CT, carotid ultrasound, aortic screening - and he said something that stayed with me: "We've gotten so good at finding things, we've forgotten to ask if finding them always helps."

He wasn't being nihilistic. He believes in screening. He's saved lives with early detection. But he's also seen the other side: people whose lives become narrower after a diagnosis of "at-risk," even when the risk is small and manageable.

There's a woman I see who had a BRCA2 mutation detected through routine genetic screening - a variant that increases lifetime breast cancer risk to about 40-60% compared to the general population average of 12%. She opted for prophylactic mastectomy - surgical removal of both breasts to prevent cancer that hadn't occurred yet. Medically, this was appropriate. It reduces her cancer risk to near-baseline levels.

But when I see her now, two years post-surgery, I'm struck by how much she still thinks of herself as a cancer patient, even though she never had cancer. The mutation defined her. The surgery defined her. She made the rational choice, the evidence-based choice. But she lost something in the process that isn't captured in our outcome metrics.

I don't have a tidy conclusion for this. Medicine has moved into territory where we're preventing diseases that might never occur, treating risks that might never materialize. Sometimes that's miraculous. Sometimes it's complicated in ways we're only beginning to understand.

What I do know is this: the next frontier isn't just better tests or more precise predictions. It's learning how to help people live well with the knowledge those tests provide. How to exist in a state of probabilistic risk without letting it become existential dread.

That's the conversation we're not having enough of. And maybe that's the real question two 98-year-olds are asking us: not just how to live longer, but how to live well in the age of perpetual diagnosis.