Popular tests, treatments may waste money and time
Editor’s note: This column will appear in Healthy Living on Sunday, April 29.
BY DR. PATRICK NEUSTATTER
A report published earlier this month might have caught your attention. It did mine. It lists a whole lot of interventions that doctors order that are very likely a complete waste of time and money—and worse, may be harmful.
The report is titled Choosing Wisely, and it was put together by the American Board of Internal Medicine and nine leading physician specialty societies in combination with Consumer Reports.
Each society came up with five interventions—which is a fancy name for tests or treatments—in its own particular field that are commonly performed but are likely of no value, such as doing Pap smears on women under 21 or giving antibiotics for simple sinus infections lasting fewer than seven days. (See the sidebar and choosingwisely.org for more details.)
The action of the American Board of Internal Medicine was prompted by an editorial in the New England Journal of Medicine written two years ago during the health care reform debate.
Medical ethicist Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas, accused doctors of protecting their income rather than trying to reduce health care costs.
Physicians’ decisions control 80 percent of health care spending, and the claim is that as much as 50 percent of that spending—representing hundreds of billions of dollars—is being wasted.
WHY THE NEEDLESS TESTS?
“What’s wrong with my doctor that he or she is ordering all these unnecessary tests?” you might ask.
And there’s the rub—and to my mind the key issue of this whole business.
As we spend ourselves into bankruptcy (health care spending is predicted to reach $4.3 trillion by 2019), more and more experts are beginning to look at, and critically question, the status quo. They are looking at the validity of the many established interventions we use whose cost is often more than just money.
There are many coercive factors encouraging doctors to order unneeded tests and treatments:
- Fear of litigation.
- Advertising that promotes tests to some extent and definitely urges both doctor and patient to want and use specific, expensive name-brand medicines—which are often no better than much cheaper generic drugs.
- Avarice—the doctor might stand to make money from the test.
Another factor is that doctors and patients feel like tests should be beneficial even if they aren’t—because more information should allay anxieties.
But the principal cause of unneeded testing and treatment is ignorance.
That might sound a bit radical. But too often we follow the “That’s the way it’s always been done” mantra and are too ignorant to know better.
Doctors are “unaware of the negative evidence behind accepted but fruitless health interventions,” noted Dr. David H. Newman, one of those who is skeptical about all the interventions we do, writing in his book “Hippocrates’ Shadow.”
The book is subtitled “What doctor’s don’t know.” In it, Newman—director of clinical research at New York’s Columbia University—knocks many sacred cows, such as antibiotics for strep throat, beta blockers for heart disease, expensive “triptan” medicines for migraines, and the validity of ECGs and mammograms.
GETTING THE FULL PICTURE
This may be making you think your care is in the hands of a lot of ignoramuses, but let me point out that being fully informed is very difficult.
There’s a lot of “lies, damn lies and statistics” about the interventions we use. Mammograms, for example, are commonly accepted as a wonderful, lifesaving intervention. They are recommended by many learned bodies because 75 percent of breast cancers are detected by mammography.
But, as David Newman points out, an in-depth overview of many studies together (a meta analysis), done by the holy of holies in the field of evidence-based medicine—the Cochrane Collaboration—looked at a thing called “number needed to treat.” It notes that you have to do a mammogram every year on 2,000 women for 10 years to save one life.
And in 10 of those 2,000 women, you will detect what appears to be a cancer but isn’t (false positive), or one that would not spread enough to do the woman any harm. This will lead to unnecessary biopsies and possible chemotherapy, radiation, surgery and, unquestionably, a lot of stress and anxiety.
And the radiation from having a mammogram will actually cause a breast cancer in one in every 10,000 women screened.
When it is put like this, many women may have second thoughts. But it very rarely is put like this.
In an article in the Journal of the American Medical Association about the Choosing Wisely program, it’s noted that the doctor discusses the accuracy of a test only 9 percent of the time, and whether it saves lives a mere 1 percent of the time.
BE AN INFORMED PATIENT
I am as guilty as any of telling my patients, blithely, “Oh, it’s time for your mammogram” and not sitting down and presenting the pros and cons in a detailed and understandable way—either because I don’t know them or because it’s so difficult or time-consuming. And this is the case for many, many interventions that we use.
This is where Consumer Reports comes in. Its part in the Choosing Wisely campaign is to work with the medical societies to produce fliers with simply-worded discussions of the pros and cons of the various intervention that are available to patients. The discussions already produced are available at consumerReports.org under “Choosing Wisely.”
So, by doing some reading, you really can have an informed discussion with—and maybe even educate—your doctor.
GROUPS LIST TESTS, TREATMENTS WORTH QUESTIONING
In the Choosing Wisely report, nine medical societies cited five interventions commonly used by those specialties that are often done unnecessarily. Each group then discussed those tests and treatments under the heading, “Five Things Physicians and Patients Should Question.”
The American Academy of Family Physicians came up with:
- Don’t do X–rays or MRI scans for low back pain in the first six weeks unless there are “red flags” suggesting such things as infection, tumors or rapidly progressive nerve damage.
- Don’t use antibiotics for sinus infections lasting less than seven days.
- Don’t do DEXA scans to detect osteoporosis on women under 65 or men under 70 with no risk factors.
- Don’t do Pap smears on women under 21 or women who have had hysterectomies for non-cancer disease.
- Don’t do electrocardiograms or other cardiac screening for low-risk patients without symptoms.
A survey done by Consumer Reports of nearly 1,200 healthy 40- to 60-year-old men and women in 2010 showed that 44 percent had received screening or tests for heart disease which the organization classified as “unlikely to have benefits that outweigh the risks.”
The Congressional Budget Office says 30 percent of care provided in the United States consists of unnecessary tests, treatments, hospital stays and other services that may not improve people’s health. Shannon Brownlee, acting director of the Health Policy Program, claims it is as much as 50 percent.
The JAMA editorial notes that these medical societies are “genuinely protecting patients’ interests and not simply rationing healthcare,” but that implementation may be difficult “when clinicians and consumers are deluged with advertising promotions.”
ON THE NET: choosingwisely.org
Dr. Patrick Neustatter, a longtime family practitioner, is the medical director of the Lloyd F. Moss Free Clinic. He can be reached at email@example.com.