The big medical news of the past week was about common sense restraint, rather than scientific advance. It was, mostly, about when not to use the medical technology at our disposal.
I refer, of course, to the "Choosing Wisely" program, set in motion last year by the American Board of Internal Medicine (my home turf), and emulated now by nine medical specialty organizations representing such disciplines as internal medicine, radiology, family practice, cardiology, and oncology.
The extensive media coverage that has ensued has, in my opinion, spent too little time on the root problem: why over-testing, which reports suggest may account for an incredible one-third of all health care expenditure in the U.S., developed in the first place. There is passing reference in most articles I've seen to profit, implying that's what this is all about -- greedy physicians who need more policing by their professional colleges -- and then the subject is dropped. Let's pick it back up, because there is more to it.
Why do excessive tests get done?
As someone who has written a textbook on evidence-based medicine, and taught the science of medical decision-making called "clinical epidemiology" to medical students at Yale over a span of roughly 10 years, I like to think my qualifications to take on this topic are good. As an emergency physician, a primary care internist, and now the director of an integrative medicine center, I have diligently avoided superfluous testing -- and even ranted against it -- for 20 years. Diligently, but not perfectly.
Here is an example of a situation -- many years ago -- when I ordered an unnecessary test. It's just one anecdote, but it nicely illustrates some of the factors in play.
A man in his early 70s came to the ER at night following a motor vehicle crash. I evaluated him in the standard manner, and was quite convinced he had whiplash-variety muscle strain -- and would be quite sore the following day -- but had no fracture. One can never be sure, however; hairline fractures are hard to detect. They declare themselves because the pain localizes and gets worse instead of better over several days, and I fully informed the patient and his wife to be on the lookout for this, which would require follow-up care.
The patient and his wife were comfortable with the assessment, but their son -- a highly educated man in his late 30s or so -- was not. He felt my care was denying his father the advantages of medical technology to save a few bucks. (Of note: As a salaried ER doc, my income was entirely unaffected by testing, and there was no pressure on me to avoid any testing I felt justified.) He insisted on X-rays.
I tried to talk him out of it, not particularly wanting to make his father glow in the dark for no good reason. I pointed out that he wasn't trusting me to decide if I needed X-rays, but would have to trust me to READ the X-rays! He just wouldn't back down.
I had patients in adjacent cubicles that were a lot sicker -- some at risk of dying imminently. I simply didn't have time to sort this out. And I knew if my patient DID wind up with a hairline fracture, this guy would be seething -- and first in line to call a lawyer. Just not worth it.
Discretion seemed the better part of valor. I sent the poor guy for head-to-toe X-rays, and have felt badly about it ever since. The x-rays were negative -- and unnecessary. Now, that's just an anecdote, but it does point out that doctors and patients can be, and in my opinion often are, in collusion about over-testing. But not always.
Sometimes, it is, indeed, about profit. One of the problems here is that procedures and the use of technology are far better compensated than the application of hard-earned knowledge to a robust decision NOT to do a procedure. Attempts to fix this systemically in medicine have thus far failed -- and need to succeed. Good medicine should be rewarded. At present, "more" medicine is.
Another issue is momentum -- often referred to as the "standard" of care. The more a test gets ordered under given circumstances, the more it gets ordered under those circumstances! What everyone is doing becomes the "standard" of care, whether it's a good standard or a bad standard, and the standard pulls everyone along with it.
At one point in my career, for example, I recall a group of cardiologists for whom the presence of a thorax seemed sufficient cause to order an echocardiogram. It wasn't any single decision that was off base; it really was the prevailing culture, or standard. So do beware the standard of care -- it can be, and often is, sub-standard.
But back to those cardiologists for a minute. There's another issue here, and it has to do with what doctors and patients have in common rather than what separates us. Namely, we are both people -- and motivated by the same basic impulses. One of which is: It's fun to play with cool toys.
As kids, we all share this penchant. But we're wrong to think we outgrow it. If you have a shiny new car, you want to drive it. If you have beautiful new shoes, you want to wear them. If you have new crampons, you want to climb a rock wall. And if you have technology that provides you a privileged view and interesting information about the inner workings of the human body -- you want to use it! From a 20-year vantage point, I truly believe that every medical specialist, however erudite, is also a grown-up kid with some very cool toys -- and he or she wants to play. It's human nature.
The Choosing Wisely campaign, which will be disseminated to the public with the help of organizations such as Consumer Reports, and AARP, has evoked criticism from some who fear it may lead to cost-cutting at the expense of useful medical procedures. If the emphasis is entirely on money, the concern may be valid. But neglecting useful tests is no better than ordering useless tests. Both are potentially costly in both dollar and human terms.
The only remedy -- what "choosing wisely" really means -- is getting the right test for the right reason at the right time. Sometimes, it's very hard to know for sure what that means -- because medical knowledge is continuously evolving. We remain mired in debate and uncertainty, for instance, about prostate cancer screening; and we have certain doubts, recently highlighted, about how best to benefit from mammography.
Choosing Wisely provides guidance about specific tests and treatments. But the issue is generalizable -- so I think the approach should be as well.
The best way to deal with all of this, in my opinion, is for you to be the boss -- provided you are a good boss. You may need your own reality check: more testing isn't necessarily better. Less testing isn't necessarily better, either. Better testing, better treatment, is better. Set your sights on the right target.
Then take control. It is your body, your health, and your life. You are the boss -- so act like it. Do not just go with the flow. Be courteous, but always assertive. I recommend the following questions as a matter of routine in response to any recommended test or treatment:
- Is this the lowest risk option?
- If not, does this approach add benefit that more than offsets the risk?
- Is this the test or treatment you would have if you were in my shoes?
- Is this the test or treatment you would prescribe for a loved one in my shoes?
- Is there another option with less risk, more potential benefit, or both -- that we should consider?
- Are you sure I need another test, and will the results change my treatment options? Can you tell me how?
- Are you sure I need a treatment, and will it reliably change my results for the better? Can you tell me how?
- How confident are you in this recommendation you are making?
A lot of truly good information can be gleaned from such an exchange, but actually, it serves another purpose too. It slows down a doctor who may be harried and hurried, and forces her/him to deal with you as... a person, rather than a patient. It may be that an emphatic introduction of the human element into the medical equation is the best defense against human fallibility. Not a perfect defense, but good nonetheless.
I have coined the term "intuistics," a blend of statistics and intuition, to describe an attribute I believe we all have: the ability to recall the patterns of prior actions and outcomes, and use them as a basis to judge whether what is going on now feels right. We tend to think of it as intuition, but I think it's often intuistics, which is based on data we don't know we know -- and thus more powerful. When that voice in your head whispers "I'm not so sure about this..." listen to it! It is probably intuistics at work behind the scenes.
And while at it, consider these two principles of intuistics: The better the question, the better the answer, and the more you know, the better you guess. Ask your doctor good questions to force good answers. Then leverage those answers into a better informed "guess" about the best course of action.
The standard of care is just... standard. Make your standard better than standard. Be a good boss -- ask good questions, get good answers. By doing so, you can help ensure that you and your doctor are always diligent, and choosing wisely -- together.
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