Patients often believe, falsely, that when it comes to medical care, more is better. So last week, when nine medical specialty societies representing about 375,000 doctors listed 45 tests and procedures that they say are done too often, it may have caused confusion and anxiety among some Americans. This anxiety is misguided. The goal of quality patient care is and always should be the same: Health care professionals should do the right thing for the right patient in the right setting with the right resources.
In keeping with that concept, the well-considered recommendations by the medical specialists are absolutely on target. Way too much testing goes on in hospitals and doctors' offices. Medicine should keep to the best practice of one doctor treating, advising and caring for one patient at a time, using evidenced-based medicine whenever possible. The reputable medical societies are calling for patients and physicians alike to look closely at hard, scientific evidence and research to scrutinize the potential benefit and harm of specific tests and procedures and to ask whether they're truly needed or if they're duplicative and wasteful.
High Costs, Mediocre Results
There's no question that the economics are unsustainable and difficult to defend for the current practice of medicine -- and that real changes must occur. The U.S. health care system is the most expensive system in the world, costing $2.6 trillion in 2010, or 17.9 percent of our gross national product. That breaks down to $8,402 per person, more than twice the average amount spent by 15 of the richest countries in the world. For such sums, we should be able to crow about our superior health outcomes and our longer lives. Not so. Compared to other countries, which utilize expensive technology such as CT or MRI scans far less than we do, too many of us die too soon of preventable, chronic diseases. And, until the provisions of the Affordable Care Act kick in in 2014 -- provided the U.S. Supreme Court doesn't strike down that law -- a huge part of the problem is that almost 50 million Americans remain uninsured. That creates not only big problems for them but also for all of us who bear a share, one way or another, in paying for their care when, for example, they end up in emergency treatment.
The High Cost of Unnecessary Tests
There are other factors besides the uninsured that drive up costs and slash favorable outcomes in the U.S. health care system. And the physician groups' recommendations take on another major problem -- how to further bend the soaring cost-curve in health care by reducing billions of dollars wasted on unnecessary and redundant tests and procedures. The Congressional Budget Office estimates that as much as 30 percent of the dollars we spend on health care gets squandered on tests, procedures, hospital stays and other services that don't help patients and may even harm them.
Why Such Over-testing?
There are many reasons for our excessive testing. Our highly fragmented health care system deserves great blame: A patient may go to one physician and leave with orders to undergo an MRI, a CT scan or multiple blood tests. But the results of all these procedures usually don't get recorded in a modern, sensible electronic records system that is integrated with other doctors' offices or the local hospital nor do physicians coordinate care sufficiently via the old fashioned telephone (or the Internet), so key information may not get shared, say with a consulting specialist, the emergency room doctor or other physicians called in a case. Tests are re-done exposing patients to more radiation, blood draws, delays and unnecessary costs. (There are efforts under way to corral providers and hospitals into reasonable and accountable teams, a topic I'll be writing about later.)
Sometimes, it's not a repeat test, but an unnecessary one that becomes problematic. Where physicians once were trained to and could spend generous amounts of time listening to patients and practicing the vanishing art of hands-on, physical diagnosis, today office visits are often rushed. I fear that some MDs, overwhelmed by new gadgets, spend too much time typing on laptop keyboards to order tests and too little effort talking to their patients. Some physicians, attempting to be fast and efficient, may use a "shotgun" approach to tests, ordering several all at once, hoping a diagnosis will emerge. A more thoughtful approach is to order the tests most likely to yield results, ordering additional exams in a rational sequence only if necessary.
We can't overlook some financial incentives in over-testing. Extra procedures can benefit physicians' bottom lines. Some practitioners, unfortunately, may hold a financial stake in tests, especially if they own or lease equipment used in procedures. A 2010 study found that one in six physicians own or lease advanced imaging equipment such as CT or MRI scans. And as long as big insurers overwhelmingly pay physicians based on the number of procedures they do, it will remain in the interest of doctors to do more. I believe most physicians strive to be thoughtful and judicious with tests but there are gray areas in medicine and a financial incentive can push the decision to order procedures rather than watching and monitoring. Clearly, the threat of malpractice litigation plays its part as a financial incentive for excess testing; too many physicians practice defensive medicine, ordering tests that may not be needed but that may help them avoid lawsuits or emerge victorious if they are sued.
Medical technology companies can take their share of credit for not only therapeutic advances but also for contributing to over-testing, as they send out small armies of sales folk to pitch equipment to doctors and hospitals. And they've been known to push beyond the science in discussing benefits of procedures employing their devices. The use of MRI technology to evaluate stroke patients, for example, went from 28 percent in 1999 to 66 percent in 2008, researchers found. But even as the researchers noted that MRI was the fastest growing component in hospital costs for stroke patients, they also wrote that the findings point to a need for more studies to understand which patients these added tests are helping and if they make a difference in patient outcomes. Without sound data, carefully analyzed, the use of technology can get ahead of any evidence of its value.
What Doctor Groups Said
The doctors within each of the nine specialties were charged as part of a multiyear effort with drawing up lists of five tests or procedures in their area of expertise that physicians and patients should question and discuss. You can see all their recommendations, specialty by specialty, by clicking here.
The cardiologists, for example, said that if a heart patient is to undergo a non-cardiac-related, low-risk surgery such as cataract surgery, it's unnecessary to perform stress cardiac imagining before the surgery.
Family physicians said that cardiac screening can do more harm than good in patients with low risk for heart disease and no symptoms.
Gastroenterologists said that in patients with average risk for colon cancer and no family history of the disease, colonoscopy every 10 years would suffice.
Radiologists said it unnecessary to do imaging for uncomplicated headaches.
Nephrologists, those specializing in kidney disease, said that when a patient on dialysis is known to have a limited life expectancy, it does not improve survival to perform routine cancer screening tests like mammograms and colonoscopies.
And difficult as it is for oncologists and their patients to accept that there is nothing left in the medical arsenal, cancer doctors laid out criteria for when to stop treatment for certain solid tumors and to begin palliative care.
Doing Your Part
Yes, knowledgeable and informed patients and families can be a boon to physicians and the health care system and it's an encouraging part of the specialists' initiative, with the aid of the foundation associated with the American Board of Internal Medicine, that it includes the support of Consumer Reports. Patients need to be smart and skeptical as they research their health needs; as I've said many times before, however, just because information is posted on a website doesn't make it true. And patients all too often now march into their doctors' offices or hospitals demanding that more be done than is medically necessary or even beneficial.
Acute low back pain without neurological impairment, for example, often goes away or responds to physical therapy and it can be needless to order a CT scan or MRI technology. Fewer of those sinus infections merit treatment with antibiotics, as many are caused by viruses that don't respond to these drugs; yes, a stuffy nose and head may not seem the biggest deal in health care but sinusitis sufferers, the specialists note, racked up 16 million office visits and $5.8 billion in costs annually. And research shows that women younger than 21 rarely need a Pap test for cervical cancer, nor do women who have undergone a hysterectomy for noncancerous reasons.
Regardless of the symptom, some patients want their physician to rule out the worst of their fears, and they want the doctor to do a procedure right away, while the still imaginary illness is curable. What often happens, instead, is that a test finds a suspicious shadow or an uncertain result that leads to more tests and possibly risky follow-up procedures.
Let's underscore a critical element about the physicians' list of 45 over-used tests and procedures: These are not commands from on high, orders for you or your physician about your individual care. The specialists are providing a launching point for a crucial conversation between you and your doctors about all your tests or procedures. If there are sound medical reasons for you to undergo a test or procedure, as carefully and thoughtfully determined by you and your doctor, this should occur -- and the specialists aren't disagreeing. You should inquire: Will this test's results reveal anything you don't already know? Will any result change your existing treatment plan? Will you be willing to accept further invasive procedures to explore ambiguous test results? If the test is for a frail, elderly loved one or someone gravely ill, will the patient be able to withstand or even accept the treatment that would be offered if an abnormal test is found?
While there may be partisans who look at the specialists' recommendations and seek to attack them with charges of "rationing" of care or by making other dark suggestions or imputing motive -- while never addressing real issues or aiming to improve our medical system -- let's underscore the significance of the doctors' move: This list could advance the national dialogue necessary so we can agree on how to improve our health care system before it breaks down. We're all paying for over-testing and unneeded procedures. And a fast way to halt this excess is to turn off the spigot for this wasteful cost. We need to not only discourage this practice, let's not fund it, via insurance or otherwise. What may be wise in medicine, society and life is that, sometimes, less truly can be more.