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When Less Is More... Mammography and Paps

By ignoring recommendations on mammography, Sebelius demonstrated why the government has been unable to rein in health care costs: Even when testing is found to be harmful, our leaders still demand more tests.
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Last week, leading experts correctly challenged long held practices in women's health. Despite the evidence, doctors and patients, as well as political and community leaders hotly debated these recommendations. My heart sank when Kathleen Sebelius, Director of Health and Human Services (HHS) weighed in and suggested that women ignore the recommendations and continue doing what they have been doing. I was astounded.

Ask any good surgeon or physician (preferably one who does not own a diagnostic machine) and we can all tell you nightmare stories about patients who have been hurt (sometimes severely) by overzealous screening and unnecessary interventions. Still, it is hard to stop something that you have been trained to do or advocate.

I still shudder, when I hear colleagues suggesting that women should perform clinical breast exams each month. We have known for over a decade that teaching women to examine themselves once a month does not prevent or improve detection of breast cancer. It does lead to more biopsies, surgeries, and anxiety (with increased cost and no benefit). The evidence against breast self exams is strong and robust. Women who identify lumps should still contact their doctors, but performing planned screening in the shower every month is simply ineffective and harmful.

Yet it's hard to stop something your doctor told you to do 30 years ago. It's also hard to stop telling patients something you learned in medical school 20 years ago. All of these recommendations represented our best advice at the time. Fortunately, we continue to learn and grow, and so must our advice.

The recommendations announced last week by the US Preventive Services Task Force (USPSTF) and the American College of Obstetrics & Gynecology (ACOG) that women reduce the number of mammograms and pap smears they receive were both founded in strong science and empiric evidence. Unfortunately, the USPSTF article reads like Greek to most non-physicians and non-statisticians.

Its critically important to realize that the men and women who develop these guidelines have no "skin in the game." They do not benefit from reducing the number of mammograms or pap smears. They're not heartless bureaucrats trying to save a few dollars. Both the USPSTF and ACOG are composed of physicians and scientists whose only motivation is to improve the health and wellness of women nationwide. Being invited onto the USPSTF or ACOG Practice Committee is a huge honor. These are our best and brightest. They strive to determine what is best for our patients, our community, and our loved ones.

Back to the reaction of Secretary Sebelius: When the captain of the ship ignores the engineer's suggestion regarding engine maintenance, it's a problem. The USPSTF is sponsored and funded by the HHS. By ignoring their recommendations on mammography, the Secretary demonstrated why the federal government has been unable to rein in health care costs: Even when testing is found to be more harmful than beneficial, our leaders and some in the media still demand more tests.

The current health reform bills have done little to change the incentives and drivers of increased health care costs. When good evidence suggests that increased testing provides no benefit, we should stop such testing. Meanwhile, as health care costs continue to grow, it crowds out money for other important areas, like education. Can we really demand medical tests that our experts suggest are unhelpful, while we increase class size in schools and cut funding to schools and our teachers?

These problems are connected. Sometimes good intentions can do more harm than good. The trust between a doctor and patient is sacred and doctors still need the ability to make individualized decisions given a patient's unique medical history. However, when it comes to standard protocols and recommendations, we must act based on the best evidence, weighing not only the benefit, but also the cost and potential for harm from a given test or treatment.

The next time a friend goes under anesthesia for a stressful, painful but benign breast biopsy, or the next time a young woman has a preterm delivery after part of her cervix was removed for an abnormal pap smear she had at age 20 (most of which resolve with time), I hope we remember that sometimes in medicine, less is truly more.