An article in the New York Times on April 4 describes a wonderful new initiative that may substantially improve the quality of U.S. health care while simultaneously also cutting its costs. Nine medical specialties have joined forces in a concerted and long-overdue effort to reduce unneeded diagnostic testing and treatment. Although the U.S. spends much more per capita on medical diagnosis and treatment than any other country in the world, we don't come close to getting our money's worth. Because unnecessary testing and treatment eat up a whopping one-third of all medical expenditures, we wind up spending a fortune for poor results on most national health outcome measures.
The new initiative by the medical specialty groups recognizes that many medical tests and procedures are not only wasteful, but also cause more harm than good. The American Board of Internal Medicine and Consumer Reports will jointly sponsor an educational program called "Choosing Wisely," aimed at changing the attitudes and habits of physicians and patients. Among the commonly overused tests that will be the target of re-education are: EKGs, mammograms, prostate studies and MRI, CT and stress cardiac imaging.
Education is a much needed first step. When it comes to medical care, people too often think that more is necessarily better. They fail to appreciate the harm that follows when promiscuous screening leads to unneeded and aggressive treatment. But education won't be enough. Things have gotten so far out of hand because of perverse financial incentives that make unnecessary procedures very profitable, and also because of pervasive physician fears that leaving any test undone will invite a malpractice suit. We need to change the incentives in the system, not just the attitudes of the participants.
How does this initiative from other medical specialties apply to psychiatry? The dis-infatuation with ubiquitous screening in the rest of medicine should provide a needed check on the premature and unrealistic DSM-5 ambition to achieve a "paradigm shift" toward psychiatric prevention. DSM-5 plans to introduce many new diagnoses that straddle the heavily-populated boundary with normality. The DSM-5 rationale (consciously borrowed from what has been tried with such mixed success in the rest of medicine) is to screen early and treat expectantly in order to reduce the lifetime burden of illness. This would be a wonderful goal, if only there were available tools to realize it. Truth be told, psychiatry does not now have any method to allow for accurate early diagnosis and we also have no preventive treatments of proven efficacy. If DSM-5 doesn't come to its senses, millions of people will be misidentified, over-diagnosed and over-treated with medicines that can cause very harmful complications.
It is sadly ironic that DSM-5 has caught the early screening, prevention bug precisely when other specialties were already discovering its risks and dangerous unintended consequences. We should learn from, not copy, painfully earned experiences in the rest of medicine and avoid expanding our boundaries before we can safely do so.
And, on another note, cautions about overuse of existing laboratory testing should also be applied to the long-awaited and much-hyped biological testing for Alzheimer's dementia. An Alzheimer's profile is still only a research tool, at least a few years away from being ready for clinical practice. But even when ready, the risk/benefit and cost/benefit analysis of widespread Alzheimer's testing should be given the kind of searching scrutiny that is only now revealing the risks and limitations of excessive screening. The lesson learned: It is not always a good idea to screen for something just because we have a test that lets us do so.
Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.
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