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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  • Anonymous

    There’s so MUCH grey area with regard to screening tests, however. It’s one thing to say don’t screen the “herd” of asymptomatic patients routinely for bladder cancer, or lung cancer, or irregular cardiac activity.

    But what about the individual patient…the one who might have no symptoms, but who has special risk factors for developing any or all of the above?

    A smoker, or person with exposure to bladder carcinogens, with close family member who have had bladder cancer…is it outrageous to test when risk is higher than the mean of the herd?
    How about a person who is or was a very heavy smoker, for a long term, or has other risk factors…but is essentially asymptomatic but for morning cough? And so on.

    The picture is even fuzzier when such a patient has vague or common symptoms. Should what applies to a healthy “herd” apply to that individual?

    It’s unfortunate but doctors will justify refusing testing because most people won’t be sick at all…and individuals who really don’t have the same risk level, will be treated like an average member of the herd.

  • Anonymous

    That’s what your annual health maintenance visit is for- reviewing your past, family and social history to see how your individual risk varies from others of your age and gender and then discussing how the population recommendations might apply to you.

    The actual “annual physical exam” is the least valuable part of this annual visit.

  • Anonymous

    It’s a pretty good post It is refreshing to hear a doctor suggest to us to say “no” – it makes us realize that at least some doctors don’t mind us doing it.

    One thing that I think the post doesn’t consider is the actual difficulty a patient may have in saying “no” to a doctor as well as lack of knowledge of most patients.

    Most patients have no way to know if a test is necessary or not. Sure, there are some who want every test they see on TV mistakenly thinking that it is necessary. But I’d suspect, the majority simply follow doctor’s suggestions. How can an average patient who is asked to do a urine test, for example, is supposed to know if it is necessary or not? For many people – if my doctor orders it, then it is necessary.

    Additionally, a doctor is a figure or authority. A doctor “knows best”. A lot of people, present company included, is very uncomfortable “questioning the doctor’s judgement”. One is afraid to be considered a “difficult patient” or “non-compliant”. Even if a test cost money and part of the deductible – as it often is in my case – it is sometimes emotionally easier to just submit than to argue. At least for me – sometimes I know that a test is no necessary and can even cause more harm, but I don’t want to “be difficult”. Or if a doctor orders multiple tests, I pick and choose “my battles” – I may refuse one but not the other so that not to “be difficult”.

    Lastly, refusal takes time. In my experience with annual physicals a non-recommended and, for many patients, unnecessary EKJ is done by a nurse before I even get to see a doctor. Asking a nurse “is it really necessary in my specific case?” and you’ll get reply “sure, the doctor ordered it”. An unnecessary urine test is just another paper slip a doctor gives you before you leave the office. By that time, your visit is almost over, and, the environment is often not conducive to additional questions.

    I stopped going to annual physicals because of that. I think I’ll go to one when I am 50 which will be in a year, just so to do colon cancer screening which is one of very few screening tests that I actually think I’ll choose to do. Beyond that – I’ll go to a doctor when I am sick.

  • Anonymous

    It is not uncommon to have a healthy patient request a CA125 to rule out ovarian cancer, like killed Golda Radner. I do not refuse but I give the patient an idea about the risk/benefit ratio, the uncertain screening interval and the population studies that show no benenfit. I also tellher that the possibility of a false positive is as high as 30% and that if she does have an elevated level, even with no other finding, I am pretty much obligated to do a laparoscopy and probably a bilateral oophorectomy, which will probably show no disease. None the less, I will get a mortgage payment out of it, or maybe a nice dinner out with my wife depending on the insurance company. So, great, go ahead and make my day!

  • IVF-MD

    Earlier this month, in one of my posts, I gave a clinical example on how to decide whether or not to do a test based on
    1. COST/INCONVENIENCE of the test.
    2. LIKELIHOOD of finding something positive
    3. USEFULNESS in how much the test results will change your medical decisions.

    Many of these screening tests are expensive on a mass basis (especially when taking into account follow-up for false positives), they are unlikely to be abnormal and even if they are abnormal, it’s not clear what actions to take to change the actual clinical outcomes.

  • Anonymous

    Or, just say yes and improve your income. Patient feels better. You feel better. Your family likes the new boat better. Your defense attorney feels better. The insurance company does not care, they just pass the rates along to the patient. So, why the fuss?

  • Anonymous

    200 million? That is nothing! Less than peanuts! That is less than a dollar per person and if that is all it costs, any benefit at all is worth it.

    But I don’t think that number is anywhere near right. There are clearly some missing zeros.

    As long as people pay for their own basic healthcare–screening is not an unexpected catastrophe and is not therefore an insurable event–I don’t see why the cost should matter if people want it. I think everyone who isn’t indigent should pay for their own.

    My objection is that if it isn’t medically indicated, then it is contraindicated because of the mischief–sometimes fatalities, that false positives lead to. The last thing I want is some serious complication of an invasive procedure to follow-up a test that I shouldn’t have gotten in the first place.

    I regret ever checking my cholesterol. Borderline numbers–which mean that, like nearly everyone else, I fall into a category where those who stand to profit from selling statins say I should be on them so I got on them. . . damned near killed me!

    Not only did I get off them, I don’t check my cholesterol anymore–felt much better when it was high.

  • Anonymous

    My doctor only did an EKG when I had an irregular heartbeat. Other than that I only get blood and urine tests each year. Urine doesn’t seem to reveal too much….maybe he’s checking for glucose (diabetes)? I know despite my youth he does pay particular attention to my cholesterol (probably because of my terrible diet)…but it’s always been good.

  • Anonymous

    Getting an annual physical reeks of hypochondria in my view. I once knew a guy who swore by annual physicals and actually advocated forcing people to get them. He always made it sound like there was something wrong with me psychologically just because I didn’t agree with him.

  • Anonymous

    It would be very easy to agree that unnecessary tests are bad – but then again, how can we find the tests unnecessary until they are taken?

    And who gets to decide that they are unnecessary? Kevin, M.D.? The insurance companies? The government?

    I believe that only I get to decide for myself what is unnecessary, and that 2 rules should follow:

    1) my physician should guide me, yet be free to refuse to order something if they feel it would be bad medicine to order it; and

    2) I should not ask others to pay for it.

    Technology today gives us the chance to detect disease sooner, often before symptoms set in. Is anyone seriously going to tell me I should not avail myself of this chance, just because they don’t want to make use of it themselves?

    The money argument gets even more preposterous. If I am paying for something myself, why should anyone say I am wasting money? One fellow may choose a top-to-bottom executive physical exam while his friend chooses a new television. It is not for me to say that one or the other wasted precious resources.

  • Anonymous

    **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**

    It is my understanding that testing for cholesterol and breast cancer have pretty conclusively shown no mortality benefit in asymptomatic individuals. This is from books by physicians who teach at Dartmouth, UNC and Columbia. Do you have information they do not have?

  • Anonymous

    As a doctor I have been telling my patients time and time again that I treat patients not laboratory results.

    Too much dependency on laboratory test dulls the clinical eye of the physician, at least in my opinion. Tests should support or rule out our differential diagnosis and should be ordered based on the patient’s history of illness and physical examination.There is no such thing as a “routine” test.

    Screening tests are ordered on a specific subset of the patient population and should be done as benefits these tests are supported by legitimate studies. But in the end, I go back to my first statement : I treat patients, not lab results.

  • Anonymous

    I agree….I’ve always been concerned about cancer screening.
    I won’t agree to it unless I’m convinced the benefit outweighs the risk…then I look at my risk profile.
    Sometimes that takes time…but I refuse to be railroaded…
    Most cancer screening tests have risks – you can be harmed and alarmed by a false positive…
    you need to know how common is this cancer, how reliable is the test, % of false positives and false negatives and what are MY chances of getting this cancer…
    Otherwise, you’ll be herded into the test with everyone else…
    I don’t accept vague answers…

    I’m afraid I don’t trust the medical profession to give me an honest and unbiased overview of a test…
    I was told cervical cancer was common…that’s not true, it’s an uncommon cancer affecting 1% of women (according to a Report from the College of Pathologists) – of that 1% – one third will have received false negatives, so screening did not help them, in fact, it may have delayed their diagnosis because the woman was reassured by the Test result and ignored symptoms)…
    So, 0.66% will benefit from the screening (in a big way) – for the other 99.33%….L. Koutsky’s research showed with two yearly screening almost 78% will have a colposcopy and possibly, biopsies with only a very small number having malignancy – Annual screening – 95%…
    So, it becomes a question of containing the harm to healthy people.
    This information is vitally important IMO to assess the risk of the cancer, the value of the screening and the risks and value of the test FOR YOU….

    So, often we’re bullied, pushed into or “required” to have these Tests – that’s wrong…
    No one has the right to assume risk on your behalf…and each of us will be happy to carry a different amount of risk and be accepting of the risk of false positives etc…
    Cancer screening is being “offered” to healthy people, so IMO the Dr is morally and ethically obliged to give you full and frank information and leave the decision up to the patient…

  • Michael Kirsch, M.D.

    Unneccessary medical care? The health care crisis will never be solved without taming this elephant in the health care reform room. For a physician’s explanation why so many CAT scans are ordered, check out http://mdwhistleblower.blogspot.com/2009/04/understanding-cat-scan-cascade.html.

    More medical are often means less medical quality.

  • http://www.yorkyates.com Dr York Yates

    Great post.

    Obviously there are certain tests that are invaluable in the diagnosis and treatment of a patient. Where this becomes a problem is when a physician orders a test with their own economic advantage as one of the factors involved with ordering the test. It sounds ridiculous that in the most noble and selfless of professions that many tests that are being ordered are largely done because physicians make money based on tests. There should be a way to regulate the bad apples such as auditing practice patterns. I am a plastic surgeon, so admittedly I have fewer tests that I would routinely order. I have seen many patients whom have been sent to me with an obviously benign “lump” in a hand or wrist that is clearly a simple ganglion cyst that have had an MRI in the workup, which is completely unnecessary for diagnosis or treatment. Lets all be responsible.

    If the results of a test do not change the treatment. DON’T order it!

    My 2 cents.

  • http://kidney-beans.blogspot.com/ dennis

    The key point in all this is the word ‘unnecessary’. It is very important to be able to tell when a particular test is deemed needed or not.

    I’ve learned this after my transplant, and tests that seemed unnecessary and repetitive being done on a monthly or bi-monthly schedule aren’t unnecessary at all.

    So what it really comes down to is what is necessary and what excessive.

  • andrew

    Tests are like Tribbles. One leads to another, and another and another.

  • Georgette

    My son had an MRI on his legs to diagnose some long-standing (>10years) lumps on his leg. The MRI came back negative but the radiologist recommended another MRI with contrast to rule out the remote possibility of cancer. I refused just as much because of the remote possibility as for my son’s inability to tolerate another MRI. His podiatrist agreed with my decision saying he had to order it as protective medicine just because the radiologist recommended it. Hey folks an MRI costs more than $3,000!

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  • Anonymous

    Of course it’s easier to tell a patient something might be wrong while covering your a** and making a little extra money too. Every human on the planet might have every disease in the book, so why not check everybody for everything?
    It makes me so mad.

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