Kevin, M.D. - Medical Weblog

My take: Just say no to unnecessary tests

This is a piece that I wrote awhile back. I have used some of the article's wording in recently published op-eds.

"Aren't you are going to order a urine test, chest x-ray or electrocardiogram?"

The patient before me was a healthy adult I was seeing for a preventive health exam. As a primary care physician, I frequently encounter similar questions. Despite lacking studies suggesting any benefit to ordering these tests in asymptomatic patients, almost half of physicians do so routinely.

Our health care system contains a myriad of incentives encouraging rampant testing. One reason is the doctor's desire to avoid lawsuits by practicing defensive medicine. Additionally, the physician payment system encourages medical excess.

Another factor flies under the radar. It takes a willing patient to partake in the overtesting phenomenon. We need to question why.

The stakes in our health system are high, and the statistics grim. Despite spending almost twice as much per patient compared to other industrialized countries, the United States ranks poorly when it comes health outcomes. Health care expenditures in 2007 totaled $2.3 trillion, and is expected to almost double over the next decade. Excessive testing, combined with the demand for the newest, more expensive diagnostic modalities, play a pivotal role in increasing costs. For instance, acquiescing to this patient's request and indiscriminately ordering routine urine tests, chest x-rays and electrocardiograms in everybody can cost almost $200 million annually.

Patients usually do not consider national health care costs when discussing the need for testing. Perpetuated by the media, the common mentality is that "more tests must mean better medicine". Gary Schwitzer, Associate Professor at the University of Minnesota's School of Journalism, leads a team that evaluates and grades health stories in the news. Regarding the media, he notes a "surprisingly strong evidence of bias" in favor of tests. Even respected health journalists and television physician personalities occasionally ignore rigorously studied clinical medicine guidelines. Explaining evidence does not lend itself to sound bites, which often diminishes discussing the risks of a diagnostic test.

Every test has the possibility of a "false positive", defined as a positive result in the absence of disease. A relatively accurate study like a mammogram has a false positive rate of 5 percent. Contrast this to a urine test screening for bladder cancer, which at 35 percent, has a significantly higher false positive rate. False positives lead to progressively more invasive tests - like a needle biopsy or CT scan - where the complications become more dangerous. Consider that a needle biopsy can lead to significant bleeding and infection, and a single CT scan exposes the patient to potentially cancer-causing radiation equivalent to 400 chest x-rays.

Granted, many tests are beneficial. Screening studies looking for abnormal cholesterol levels, colon cancer, breast cancer and cervical cancer have been shown to save lives. If a patient has a concerning symptom, obtaining the appropriate test is imperative. However, subjecting the healthy population to unproven tests does not necessarily yield better results. In fact, data suggests that more intensive medical care can be associated with worse outcomes coupled with an increasing degree of medical errors and cost.

The public should be pro-active addressing the complications of medical procedures and imaging scans, especially if their doctors don't. Studies have shown that patients tend to decline tests of questionable benefit when they are aware of the true risks. Understand that there is pro-testing bias in the media. Anecdotes of catching disease impact emotionally on TV and sell newspapers. Explaining medical evidence doesn't inherently have a "human side", and is subsequently downplayed. Health stories should be critically analyzed before being believed.

Back to my patient, who is waiting for an answer. Major guidelines recommend against ordering a routine urine test, chest x-ray, or electrocardiogram for the screening of bladder cancer, lung cancer, and heart disease respectively. There are no studies suggesting any improvement in patient outcomes by ordering these tests in the asymptomatic patient.

The answer is clear.

We need to say no to unnecessary tests.

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