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.”