The Testing Glut

In case you missed it, a recommendation came out last month that physicians cut back on using 45 common tests and treatments. In addition, patients were advised to question doctors who recommend such things as antibiotics for mild sinusitis, CT scans for an uncomplicated headache or a repeat colonoscopy within 10 years of a normal exam.

The general idea wasn’t all that new — my colleagues and I have been questioning many of the same tests and treatments for years. What was different this time was the source of the recommendations. They came from the heart of the medical profession: the medical specialty boards and societies representing cardiologists, radiologists, gastroenterologists and other doctors. In other words, they came from the very groups that stand to benefit from doing more, not less.

Nine specialty societies contributed five recommendations each to the list (others are expected to contribute in the future). The recommendations each started with the word “don’t” — as in “don’t perform,” “don’t order,” “don’t recommend.”

Could American medicine be changing?

For years, medical organizations have been developing recommendations and guidelines focused on things doctors should do. The specialty societies have been focused on protecting the financial interests of their most profligate members and have been reluctant to acknowledge the problem of overuse. Maybe they are now owning up to the problem.

And judging from the content of the list, testing is a big part of that problem. Only a quarter of the recommendations fell in the category of “don’t treat” — as in, don’t prescribe more chemotherapy for end-stage cancer that is beyond hope. The remainder fell in the category of “don’t test.”

Because it can be the first step in a cascade of medical interventions, the focus on testing makes good sense. The specialty boards seem to now recognize that the results of testing include both signals (useful information) and noise (false and distracting information). For patients with symptoms the signal predominates. But for those without symptoms the noise predominates. And the noise is not harmless, it can trigger overdiagnosis and overtreatment. “Routine” chestX-rays, for example, have a way of unearthing multiple abnormalities. This raises questions in physicians’ minds — triggering CT scans, needle biopsies, bronchoscopies and even surgery in an effort to answer them.

That’s why multiple recommendations have argued against routine use of tests such as cardiograms (EKGs), ECHO and CT scans in asymptomatic patients — and against repetitive testing in patients whose symptoms have not changed.

Admittedly, some of the recommendations seem brain-dead obvious.

Don’t screen for cancer in dying patients. (How could they possibly benefit from the early detection of a cancer that will not have time to progress?)

Don’t screen for cervical cancer in women who don’t have a cervix. (How could they possibly be at risk for cancer in an organ they no longer have?)

You might think such guidance would be unneeded. Sadly, research using the Medicare data has demonstrated both those things regularly occur.

Other recommendations have been around for years. Don’t order CT scans and MRIs on patients with nonspecific low back pain. Don’t order routine preoperative chest X-rays. Yet those orders continue.

Most doctors will agree with the recommendations on the list. But the problem of overuse is less one of bad doctors (although there are a few); the problem is more one of good doctors working in a bad system.

The truth is there are many forces that push us to do more. There are the performance measures that typically give doctors good grades for ordering tests, rather than for not ordering them. There is the legal system that will punish us for underdiagnosis, but not for overdiagnosis. There are the demands from patients seeking to get their money’s worth from insurance after years of being taught to believe the best medical care is the most medical care. And there are the financial rewards: Most doctors, and/or the clinics and hospitals they work for, are paid more if they do more.

But we have to start somewhere — and this list is a good start. Now it needs to be extended.

Personally, I would have liked to see the recommendation “Don’t perform breast or prostate cancer screening unless the patient understands both the harms and benefits.” Or perhaps we could think even more broadly: “Don’t feel compelled to end every patient encounter with an order for a test, a recommendation for a procedure or a prescription for a medication.”

H. Gilbert Welch is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. He is the co-author of Overdiagnosed: Making People Sick in the Pursuit of Health. This post originally appeared in the L.A. Times.

9 replies »

  1. In response to the patient with the “suspected abnormality” on mammogram. I, too am one of the women who has insisted upon “shared decision-making” with my doctor. I, too, have educated myself about over treatment, false positives, mammograms and many other tests. I feel as if I am pushing my doctor to do something she is not comfortable with by discussing this and refusing to have a surgical biopsy and instead choosing to rely upon self and doctor breast exams. As a psychologist, I am acutely aware of the mental health ramifications of becoming a cancer patient needlessly or living with the knowledge that you might one day discover a malignant cancer. It is a very personal choice that can only be fairly made with “shared decision making”. I am a huge fan of Dr. Welch and his group at Dartmouth and their very important research and clear writing both for medical colleagues and for the public.

  2. Excellent point about shared decision making. Very interesting to know that an actual law has been passed in Washington for that type of truly informed consent. As someone who has been grappling with a mammography issue, and educating myself about biopsies, etc. I have tried to put into action the type of dialogue with my doctor as to how much I know (a lot) about mammograms, false positives, overtreatment. So far, it seems to be a positive thing and has resulted in me NOT having a biopsy as of yet for a very small “suspected” abnormality on mammogram. I hope every state passes a Shared Decisionmaking law, indeed, it would cut lawsuits a lot and everyone would be truly informed consumers about their health and testing. Bravo also to Dr Welch, he’s a true advocate for patients!

  3. Dr. Mike-

    One of the very best ways of protecting doctors against suits (and fear of suits) is to pass a law that makes it very difficutl to sue a doctor if he has followed “shared decison-marking” protocols.

    This means giving a patient full information about the potenetial benefits and risks of the test or procedure in question. (Yes, tests carry risks. As you know, they can lead to over-diagnosis, false positives, and unncessary treatments– with side effects.)

    Experience shows that when doctors share the decisions-making in this way, a great many patients no longer as eager to undergo the test or procedure.

    The state of Washington has passed such a law.

    Shared Decisionmaking can achieve two goals: reduce overtreatment, and reduce suits. (Research also shows that when patients are givien the infromation to make an “informed decision” rather than passively giving “infrormed consent,” they are much less like to experience regret–and blame the doctor..

  4. I know y’all don’t want to hear it, but doctors will continue to ignore the list and the recommendations until there is tort reform. That’s the consensus on both the Sermo and MedScape physician forums. There is no protection for denying a patient a test they desire even if the test is not indicated. Caps on ecomonic damages are not tort reform, so don’t give me that line about how tort reform has failed.

  5. Do we think there’s ANY chance at all of improved public understanding Bayes’ Theorem as it bears on the net utility of diagnostic tests?

  6. “Most doctors will agree with the recommendations on the list. But the problem of overuse is less one of bad doctors (although there are a few); the problem is more one of good doctors working in a bad system.”

    This sounds like a political campaign “half-jab” at a straw man or, at least, damning docotrs with faint praise. The “Choose Wisely” participants did note that patients’ desire for a test that “they had heard about but did not need” was a significant cause of needless testing. Inclusion of that point in your blog might have reduced the campaign memo tone.

  7. All my heart tests turned out to be good and yet a doctor wants me to take this medical stress test which I feel is risky and with side effects. and I understand it could take up tp four hours I am 5 with blood pressure that elevates with doctors due to a anxiety disorder. Is this one of the procedures listed? I recently had a scare but I think it was only acid reflex and not a heart attach.

  8. Mostly agree, but there are some more factors worth mentioning: patients who want to have every conceivable test, often because they have anxiety- and/or somatization disorder – I see on a daily basis that there is a small fraction of organically healthy (or mostly healthy) patients that rotate through ERs and/or various specialty clinics.

    Moreover, there is a medical culture (this includes patients, relatives, nurses and doctors) in which thoroughness is confused with ordering plenty of exotic tests/fancy scans, and “House” and “Mystery Diagnosis” provide misleading modeling.

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