Sometimes a screening leads to a false positive, after which additional tests can expose patients to unnecessary radiation or even biopsies, which carry their own risks. Other times an imaging test may pick up an abnormality or even a cancer that simply is not life-threatening. Moyer points out that women have gotten mastectomies to treat small, nonaggressive cancers that were never going to affect them. “That’s a huge harm,” she says. Yet it can be difficult to convince people that it’s okay to simply live with a cancer.
“The assumption has been throughout history that the more you know about human normal function and disease, the better equipped you are to treat disease and restore health,” says James Froehlich, the director of vascular medicine at the University of Michigan Medical School. “There are two problems with that. One is the assumption that the goal of medicine is to make people normal again. The other fallacy is that attempts to do so will lead to better outcomes.”
Researchers are finding that trying to make patients “normal” again or even finding out if a patient has something “abnormal” can lead to harm without changing the course of a disease or a patient’s outcome. Aside from excess radiation or treatment side effects, the often debilitating anxiety that screenings can cause are also harmful, says Rich Sagall, a family medicine physician in Gloucester, Mass. “One question every patient should ask before submitting to any test is, ‘How will the results of this test influence the treatment plan?’” Sagall says. “Oftentimes it turns out it won’t.”
That question also gets to the heart of another goal of Choosing Wisely: improving patient–doctor shared decision-making.
Improving communication between patients and providers
Froehlich points out that the health care industry is much less efficient at providing consumers with information than almost any other industry. “It’s been frequently commented that you can make a more informed decision about a car than about a surgeon,” Froehlich says. “The point is that we all have a better idea of whether the brakes need to be changed than if we need a CT scan. This campaign is meant to empower a dialogue so there’s a better discussion about tests and procedures.”
That dialogue is most successful, though, when consumers understand before they get sick that screening and treatment can cause harm. “It’s hard to process more complicated decision-making if I’m already sick,” says Glen Stream, a member of the AAFP. “It’s better if I’ve already given some thought to the idea that perhaps the best treatment is no treatment.”
Understanding risk-benefit analysis of procedures can also help reduce the influence of fear on decision-making. “Post-diagnosis is a hard time to begin that conversation, because the patient is scared,” says Daniel Barocas, an assistant professor of urology at Vanderbilt University Medical Center. “If you tell someone they have what they perceive as a lethal disease, they’re going to seek treatment. This effort encourages discussions where doctors and patients can let data and evidence run the show a little instead of emotionality and fear.”
Barocas says he therefore counsels his patients before any tests for prostate cancer that they may “find something called cancer that doesn’t need treatment” because low-risk, slow-growing prostate cancer is often unlikely to harm a man before he dies of other causes. “I make them promise me they’ll listen to me longer than the word ‘cancer’ before deciding what they want to do,” he says. But he adds that this campaign doesn’t mean screenings have no value. “None of these is a ‘never’ event,” Barocas says. “It’s just not something you have to do routinely.”
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11 Comments
Add CommentIt seems to me that a major part of the problem is that doctors now treat consumers instead of patients. Most doctors are in a commercial enterprise whose end purpose is to pay off educational debt and to acquire personal wealth.
Reply | Report Abuse | Link to thisI think it is common practice for doctors to purchase their own equipment to perform these tests in order to increase their own profits. This represents a conflict of interest that is unethical and should be illegal.
It is so hard these days to find a doctor that really wants to help his/her patients get well.
I remember when docs began to ramp up testing when malpractice awards began to skyrocket then it's morphed into a business as outlined in the article. We've got to slow down and not demand services that are not goal oriented. Docs need to read the handwriting on the wall before the government really steps in to control costs.
Reply | Report Abuse | Link to thisNot all of this can be blamed on the doctors. I know multiple physicians that have complained about having to jump through multiple hoops to try to do the best thing for the patient.
Reply | Report Abuse | Link to thisFor instance many insurance companies refuse to cover an MRI unless the physician orders a CT scan first (regardless if the MRI is the better test for the situation) because the CT is cheaper for them. Even if the Dr. knows the CT probably wont show them what they want to know, they have to order it first so a patient doesn't have to pay out of pocket for the test they actually need but couldn't afford.
Plus, the constant threat of a malpractice suit has pushed the medical community towards aggressive testing. It's now safer for a physician to over-test to be thorough, than to risk being sued and accused of negligence. It's great to teach patients that not all tests are necessary. I doubt that a malpractice lawyer will see it that way, however.
Don't get me wrong, I agree with the article that the usefulness/consequences of tests should be viewed objectively. I also feel national guidelines should reflect the facts. My objection is when the blame is placed solely on the shoulders of the physician. Malpractice threats and insurance obstacles have far more influence on this than people realize.
MRI scans do not subject patients to ionizing radiation as the caption on your image tends to suggest.
Reply | Report Abuse | Link to thisI am thrilled to see this article,especially following the Times article "Bitter Pill" yesterday. This kind of information hasn't made it to the mainstream TV news but hopefully with nudges from quality journalism, it will. The culture of "What's your colesterol count" and "Have you had your colonoscopy" and "there's a pill for that" needs to change. We are overtreated and underserved by the medical system comprised of physicians, hospitals, big Pharma, medical device manufacturers and insurance companies. We can help stop this by refusing unnecessary testing and treatments. Your insurance may pay it, but what are you paying for your insurance? What are we all paying?
Reply | Report Abuse | Link to thisBooks written on the lack of a free market in the medicalization of our society are plentiful, but most people don't read nonfiction books. That's why I'm so excited by these articles. If you really want to get revved up by this topic, read "Bad Science", "Overdiagnosed", "Catastrophic Care", "Worried Sick", and "Doctor, Your Patient Will See You Now".
Few of the players in this game are evil - but many are greedy. Educate and protect yourself.
Thank you, Scientific American, for this article.
Who is paid to keep people healthy? No one.
Reply | Report Abuse | Link to thisWho shops for medical care? Pretty much now one.
Where do you go for information on the quality of your hospital or physician? Damned if I know.
MRC06405 : you put your finger on it. One answer should be : the insurance companies. But do they have an incentive to reduce costs, or are their profits a function of total expenditure?
Reply | Report Abuse | Link to thisAnd to be fair, they are plagued as well by law-suits and the courts.
No doubt the high cost of malpractice insurance is a key reason for imposing expensive, often unnecessary tests on patients. The bottom line is that although we have available in the US an extraordinary arsenal of tests and drugs we are far back on the list of medical results or quality; 27th worldwide I believe. We provide or have available the best medical care and equipment and we do so poorly in terms of outcomes. Incredible! A second reason is that there are among our medical professionals a small cadre of real dum dums who should not be allowed to practice. If our doctors rose up and demanded that they be removed or otherwise made them non practicing by speaking out, the high cost of malpractice insurance would be eliminated. Lawsuits that result when things go awry should have very limited awards so as to reduce the number and cost of such lawsuits. This would also reduce the cost of malpractice insurance. Once that is accomplished the number of unnecessary or marginal tests would be reduced and the need for high performance test equipment would be reduced. Why do we annually kill 100,000 hospital patients and cause 2 million infections annually by use of totally ineffective hand sanitation means? The associated cost is $40 billion. Why do nurses and doctors use ineffective alcohol rubs to sanitize their bare hands and moreover do it less than 50% of the time, doing nothing to sanitize hands between patients the rest of the time. It is not as if there is not an ultrafast, 1000 times more effective, 20 times less costly means to sanitize bare and gloved hands between patient visits. Something is very fishy in Denmark USA.
Reply | Report Abuse | Link to thisDr's are regularly sleep deprived .
Reply | Report Abuse | Link to thisThey of all people know that is not a good thing for themselves or their patients .
Better decisions will be made when a proper sleep pattern is a requirement !!!
I attest to having Cigna, my insurer, mandate that I got CT scans before then getting MRIs for conditions in which the standard for care medically is an MRI. The attempt to save money is wasteful and nonsensical. Is the insurer dictating my diagnostic and treatment protocol or is the doctor? If the patient protests, then the patient becomes "non-compliant," according to some attorneys. A system run by non-medically educated insurance executives has proven to deliver less than adequate medical care. Pennywise and pound foolish wasting both patient and doctor time doing what both know makes no sense other than to please the payer.
Reply | Report Abuse | Link to thisI was baffled learning that I had to run through a checklist of standard tests to "rule out" possible illnesses before any specific tests could be run to address my health complaint. I changed primary care physicians three times and each time encountered these same battery of tests (which had nothing to do with my complaint. All came out negative because I am not overweight, work out, eat healthy. The doctors then said that I must be all right since their tests (none designed to address my complaint) were all negative. I then learned most conventional doctors have no training in detecting systemic fungal infections, hypothyroidism, adrenal fatigue, food sensitivities, autoimmune diseases... When does listening to the patient's concern ever enter the picture?
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