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Virtually
every family in the country, the research indicates, has been subject to
overtesting and overtreatment in one form or another. The costs appear to take
thousands of dollars out of the paychecks of every household each year.
Researchers have come to refer to financial as well as physical “toxicities” of
inappropriate care—including reduced spending on food, clothing, education, and
shelter. Millions of people are receiving drugs that aren’t helping them,
operations that aren’t going to make them better, and scans and tests that do
nothing beneficial for them, and often cause harm.
Doctors
generally know more about the value of a given medical treatment than patients,
who have little ability to determine the quality of the advice they are
getting. Doctors, therefore, are in a powerful position. We can recommend care
of little or no value because it enhances our incomes, because it’s our habit,
or because we genuinely but incorrectly believe in it, and patients will tend
to follow our recommendations. Overkill
The studies just
continue to pile up about the high costs and negative impacts of being over
tested and treated, with the most recent one published in PLoS One, confirming
what’s been known for a long time, doctors practice defensive medicine. In
other words, they don’t want to be sued so they over test and over treat “just
in case.”
Economics is also an
issue. Paying physicians a fee every time they provide a service
encourages them to order more tests and procedures. Equally important are
patient expectations of more tests, treatments, pills etc. One of the best examples
of the latter was the backlash when the US Prevention Task Force came out with
its recommendations on mammography. Women continue to follow old standards in
the belief they were doing something to prevent breast cancer.
We’ve
long assumed that if we screen a healthy population for diseases like cancer or
coronary-artery disease, and catch those diseases early, we’ll be able to treat
them before they get dangerously advanced, and save lives in large numbers. But
it hasn’t turned out that way. For instance, cancer screening with mammography,
ultrasound, and blood testing has dramatically increased the detection of
breast, thyroid, and prostate cancer during the past quarter century. We’re
treating hundreds of thousands more people each year for these diseases than we
ever have. Yet only a tiny reduction in death, if any, has resulted.
Called “low value
care,” it could easily become “harmful care.” For those with chronic
conditions, where both provider and patient are looking for answers, it’s
possible that they may be the most vulnerable. The least impact is that nothing
happens but your still out the cost of extra testing and/or treatment as well
as your time. The worse is that it can actually make you a lot sicker as well
as create unnecessary anxiety over something that wasn’t a problem in the first
place. Excessive testing just isn’t financially costly, but the more tests
ordered the greater the risk of a false positive. In the case of CT scans and
other forms of imaging, the more you receive, the more radiation you are exposed to.
The article Overkill by Dr. Atul Gawande is an excellent
overview of unnecessary care and would recommend taking the time to read
it.
To avoid unnecessary
care, Consider the following:
1. Be a willing partner to “shared-decision
making.” Recognize that
while your provider knows a lot about their field, you know yourself better
than they do. If they prescribe medication you know you’ll never take or wont
take as prescribed, this is important information to discuss. Fortunately, many
hospitals and even condition specific organizations offer shared decision
making tools to help both you and your provider. Your provider should explain
your condition; take time to understand your goals and concerns; explain the
latest medical evidence as well as benefits and risks of options, including
doing nothing; explain things in a language you understand; listens to you; and
helps you make decisions after considering all the options. Ultimately, you
have to live with the choices made, so learn to become a good medical decision
maker.
Resources
2. Check current recommendations
for testing and treatment. There are several groups/panels of medical
providers that make recommendations based on evidence. Check these out for
recommendations regarding testing, treatment etc. Also contact your condition
specific organization (e.g. American Diabetic Association) to discuss their
recommendations. As each patient situation is unique, providers and patients
should use the recommendations as guidelines to determine an appropriate
treatment plan together.
Resources
• US PreventiveServices Task Force (USPSTF) created in 1984, is an independent,
volunteer panel of national experts in prevention and evidence-based medicine.
The Task Force works to improve the health of all Americans by making
evidence-based recommendations.
• ChoosingWisely is an initiative of the ABIM Foundation in
partnership with Consumer Reports that seeks to advance a national dialogue on
avoiding wasteful or unnecessary medical tests, treatments and procedures. They
offer a variety of lists that were created by national medical specialty
societies and represent specific, evidence-based recommendations clinicians and
patients should discuss. Each list provides information on when tests and
procedures may be appropriate, as well as the methodology used in its creation.
Choosing Wisely has an App that you can use on your phone at your medical
appointments.
3. Question “lets get some lab tests.” Ask how many, why, what information will
they provide and what are the costs? The more tests ordered the greater the
risk of a false positive, which can ultimately lead to a care plan that isn’t
right for you. In cases where there are unusual circumstances, such as you’ve
been having strange symptoms that no one can seem to figure out, a scatter shot
approach to testing may be appropriate. However, if this is just a normal
situation, don’t settle for vague answers to why tests are needed.
4. Be wary of generalizations about medications. You need to know how a medication will
directly impact your health situation. What are potential side effects? Costs?
Are there generics for the medication? Is there an alternative approach that
can be taken?
5. Are you continually being referred to
a specialist for one reason
or another? This could be an indication that your primary care provider is
overwhelmed and it’s time to look for a new one.
6. Technology such as CT scans and MRIs
should only be done when medically necessary. The better the technology, the more likely it
is to find something that may not be dangerous. CT scans and MRIs while very
helpful in diagnosing a problem, can pick up normal imperfections, that
wouldn’t cause harm, but can precipitate additional testing and treatment.
Additional Reading
• Overkill by Atul
Gawande An avalanche of unnecessary medical care is harming patients physically
and financially. What can we do about it?
