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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Want my take?

This is a periodic open thread to solicit issues people want me to blog about. Suggest topics and links in the comments of this post, or you can e-mail me.

I'll choose a few to put into my regular "My take" feature.

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MedBlog Power 8

4/30/2008 - 5/7/2008
Next revision: 5/7/2008



(Key: Rank, Blog name, Last week's rank, Post of note)

1) Dr. Val and the Voice of Reason (-), A Surgeon General's Opinion: Preventing Chronic Disease

2) The Happy Hospitalist (2), Coding Clinic. Inaugural Edition

3) WSJ Health Blog (-), Call of Medicine Gives Way to Family Tug

4) Health Care Renewal (-), The AAMC Report on Medical Schools' Industry Relationships: A Glass Half Empty

5) Health Beat (4), Can Big Tobacco Snuff Out Health Care Reform?

6) DB's Medical Rants (6), Training then, training now

7) Dr. Wes (7), 1984

8) ER Stories (3), A Homemade What?!?!

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

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That's pretty nasty

Read why.

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Health insurance is the new Green Card

WSJ Health Blog: "Seven percent of Americans said that in the past year they or someone in their household decided to tie the knot mainly so one spouse would be eligible for the other’s health coverage."

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Relying on prayer, prosecuting the parents

Orac: "That is why I am heartened to see the Neumanns prosecuted, even though it may well be an uphill battle to obtain a conviction. So great is our deference to religion in this country that I am not at all confident that the Neumanns won't get off scot-free and even ultimately regain custody of their other children to have another chance to do it again."

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Note to politicians: Balance billing is essential

The Happy Hospitalist: "My biggest problem, which I think outweighs all other issues in the health care. And that is balance billing. Payment rates by our government and followed by all third party payers have decimated cognitive medicine, the exact saviour of McCain's proposed market system. Without balance billing, we will never have a market force in health care. Without balance billing, primary care will never return. Without balance billing access will die a rapid death."

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Insulating your practice from Big Pharma

Concupiscent Curds: "I still fool myself sometimes thinking I've sterilized my practice from Big Pharma. But I haven't and I'm not sure I could completely. I am always on guard, though, against them trying to cozy up to me. In fact, one rep came close to actually becoming a friend until I realized what was going on and learned that a key lesson in the education of a rep is to befriend the doctor."

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More on doctors getting a life

Toni Brayer: "Young physicians do not want to deal with office employees or running a business. They expect a full schedule of patients to be there and an office administrator to deal with other business aspects like contracting with insurers, collecting payments and worrying about Medicare hassles.

The problem is that primary care practice and even some specialty practices have not been set up this way."

Practices are going to be forced to change to have any success recruiting the new-generation lifestyle physicians. I have no doubt that it will happen, despite the resistance the retiring doctors are putting up.

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Doctors with MBAs

Any physician who recognizes that good business skills is essential in medicine is ahead of the curve:

"Medical schools have done a horrible job preparing physicians to enter into private practice. They don't give them any understanding of debits and credits, what it's like to run a small business. They're prepared to be clinicians, not to run their practice."

Some sort of business training should be mandatory prior to becoming a physician.

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Insidermedicine: In the Clinic - Unusual loss of visual acuity

In the Clinic Tip - Unusual loss of visual acuity (Presented by Dr. Sanjay Sharma, MD)

Thanks to Insidermedicine for their continuing sponsorship at Kevin, M.D.

Insidermedicine (www.insidermedicine.com) is a physician-led news organization that brings daily evidence-based updates to patients, doctors and medical students. Also available in Chinese and Spanish.

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iMedExchange

I would like to thank iMedExchange for their continuing Premium Sponsorship at Kevin M.D.

If physicians want it, iMedExchange is building it...

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Not satisfied to merely provide clinical information and resources, the iMedExchange model takes into account the additional pressures and challenges facing today's physician. Not only are they providing the forums and clinical information physicians want, word on the street is that they are using Web 2.0 technology to help physicians in their business -- like help with finances and healthcare technology -- and even for leisure, like sharing great wine tips.

Most recently, they built a tool that lets its members create their own groups, giving physicians the opportunity to have private conversations with other physicians who share their specific interests and issues.

iMedExchange technically hasn't launched yet, but physicians can still join the site as they build it. Almost every time you log in there is a new tool or feature. Log in at www.imedexchange.com (they verify that you are a physician before you can enter the site) and start using their forums and groups.

Sponsorship opportunities continue to be available. This can be via a Standard Blogad or a customized package. Please visit the advertising information page for further details.

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My take: Preventive care, geriatricians, lifestyle

1) 80% of preventive care occurred outside of yearly physicals.

My take: Interesting study questioning the usefulness of a routine physical. In many cases, unnecessary tests are performed during these visits, driving up health care costs.

However, I find a routine preventive health visit helpful. It is a way to consolidate a patient's screening status in a setting where preventive care takes priority. This enhances the probability that the patient is up to date with the appropriate screening tests, rather than tacking it on at the end of an acute visit.

2) The number of geriatricians declined 22 percent since 2000.

My take: That's a pretty frightening statistic considering we are on the cusp of the Medicare baby boom era.

Primary care physicians are already under siege. Geriatricians are compensated even less. Hard to believe the short-sightedness going on here.

3) Jacob Goldstein, who runs the WSJ Health Blog, has a front page article discussing the priority new physicians place on lifestyle. Older physicians are resentful:

"It really gets on your nerves when you get these young guys coming in and interviewing and they say, 'I'm not doing this, I'm not doing that.'"

My take: Deal with it. Placing an emphasis on lifestyle makes for happier doctors who are less prone to burnout. With physicians being held in lower regard these days, it is no wonder more are seeing medicine simply as a job, not a calling:

Walter Cheng, 32 years old, is in the profession's new guard. Upon graduating from the Johns Hopkins School of Medicine in 2004, he bristled at the notion espoused by some senior physicians that a doctor should put medicine above all else. "I thought, 'I don't really want to be that kind of doctor.'... My family is as important, if not more important, than my career."

Well said.

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Are you a Super Doctor?

And should you want to be one?

Do these lists really measure quality? I don't think they do. If there is no vetting of who gets the surveys in the first place, then the results are really just a mish-mash of referral patterns across and between specialties. I've always been surprised at seeing who is on and off Castle-Connolly's list in New York Magazine, since it seems more hit and miss than anything else.

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Grand rounds is up

Doc Gurley hosts the weekly best of the medical blogosphere.

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Tobacco dependence and disease mongering

Bioethics Forum: "It is almost as if these companies had made a joint decision to cast smoking as a chronic disease in order to reposition their products as long-term maintenance medications, like methadone. Smoking cessation is painted as a goal unachievable without pharmacologic assistance. Nicotine, the addictive component in both cigarettes and nicotine replacement products, is portrayed as harmless in medicinal form, as is buproprion (which can cause seizures) and varenecline (which has been linked to psychiatric disturbances, including suicidal ideation and suicides)."

(via Health Care Renewal)

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MedBlog Power 8

04/23/2008 - 04/30/2008
Next revision: 04/30/2008



(Key: Rank, Blog name, Last week's rank, Post of note)

1) Aggravated DocSurg (-), We Don't Speak the Same Lingo

2) The Happy Hospitalist (3), We Fuk'd Up. Sorry 'Bout That

3) ER Stories (4), Transfer Ethics

4) Health Beat (1), Evidence-Based Mental Health Treatments: Lost in Translation

5) edwinleap.com (-), Charting…yuck!

6) DB's Medical Rants (8), The idiocy of productivity measures

7) Dr. Wes (5), The Electronic Nursing Note

8) Diabetes Mine (7), Why Testing Matters (Use It or Lose It)

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

Posted by Kevin | link | Comments (0) |

Life of a hospitalist: "A highly paid intern"

Hospitalist medicine is similar to what internal medicine residents do in the hospital. That's part of the appeal for newly graduated doctors who want to continue to do what they're familiar with.

After a few years of doing this, you start to realize that there's more to medicine than scutwork.

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"His penis was basically sitting in a small pool of old urine"

Please, urinary catheters are not meant to be home-made.

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Traffic cameras and P4P

Dr. Wes: "I saw this ticket as an extreme example of "Pay for Performance (P4P)" - just like we are implementing in healthcare. P4P is another government-mandated endeavor to assure the best quality of healthcare through the use of "absolute truths" agreed upon by a body of experts. There can be no room for negotiation, no original thought involved. Follow the rules and you will get paid.:

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When lawyer's antics go too far

There's hope in reining in inappropriate conduct by plaintiff's lawyers.

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An obese prisoner sues the jail

For not feeding him enough.

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The cost of giving patients time

Burnout:

"Medicine has ceased being a pleasant job, except for the patients. If you're not made to be a doctor and willing to put up with all of this for the joy and gratification of a job well needed and well done, it just isn't worth the trouble. So many doctors just quit. They get a more defined job. They get a salaried job."

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ScrubsGallery.com and MagsDirect.com

I would like to thank ScrubsGallery.com and MagsDirect.com for their continuing sponsorship at Kevin, M.D.


Buy scrubs with a 30 day money back guarantee on unopened products with no restocking fee.



Magazine subscriptions with the lowest prices allowed by publishers. Free shipping and no sales tax.

Sponsorship opportunities continue to be available. This can be via a Standard Blogad or a customized package. Please visit the advertising information page for further details.

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My take: Colon cleansing, patient satisfaction

1) A reader writes: "I would really like it if you could blog about all the craziness involved with detoxification and cleansers."

My take: I wrote about it a few years ago. For more, I'm going to defer to the woo-busting king, Orac.

2) A reader writes: "I'd like to hear your thoughts on this growing concept of healthcare customer service."

My take: Physicians can certainly do a better job communicating with patients and improving the patient experience. Shorter wait times and improving access to the system would be two examples.

However, there are cases where what's best for the patient may not always be congruent with good customer service. If a patient demands an unnecessary test or medication, should the physician acquiesce in the name of keeping the patient happy? How about the drug-seeking patient demanding narcotics?

More worrying is that compensation is increasingly linked to patient satisfaction scores. I can see some doctors caving in to questionable patient demands simply to keep their scores high, and maintaining their incomes.

Posted by Kevin | link | Comments (6) |

Want my take?

This is a periodic open thread to solicit issues people want me to blog about. Suggest topics and links in the comments of this post, or you can e-mail me.

I'll choose a few to put into my regular "My take" feature.

Posted by Kevin | link | Comments (0) |

Touching a patient

Victoria McEvoy: "Let's face it, human sexuality is often the elephant in the room when doctors and patients interact. Or, I should say, perceived sexuality. What may seem like prurient interest from the patient's point of view may be just another breast exam, pelvic, or mole check in a busy afternoon. What can be deeply mortifying for a patient does not even register on the radar of a busy physician. After all, it is our job to look for wayward moles on hidden spots, check for hernias in an embarrassed young male, and to provide preventive care for sexually active young people."

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Satisfied with your health care?

An oft-neglected statistic showing that satisfaction with American health care is on the rise.

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When Big Tobacco halts health care reform

Maggie Mahar: "That an industry that manufactures poison has been able to block health care reform is not just ironic, it's tragic. Going forward, reformers need to push back by reminding voters that if all Americans stopped smoking—beginning with this generation of teens—that would do more to improve the health of the nation that any other reform."

Posted by Kevin | link | Comments (2) |

Does evidence-based medicine raise costs?

Peter Pitts thinks so, but Roy Poses shoots down his arguments.

Posted by Kevin | link | Comments (0) |

MedBlog Power 8

04/23/2008 - 04/30/2008
Next revision: 04/30/2008



(Key: Rank, Blog name, Last week's rank, Post of note)

1) Aggravated DocSurg (-), We Don't Speak the Same Lingo

2) The Happy Hospitalist (3), We Fuk'd Up. Sorry 'Bout That

3) ER Stories (4), Transfer Ethics

4) Health Beat (1), Evidence-Based Mental Health Treatments: Lost in Translation

5) edwinleap.com (-), Charting…yuck!

6) DB's Medical Rants (8), The idiocy of productivity measures

7) Dr. Wes (5), The Electronic Nursing Note

8) Diabetes Mine (7), Why Testing Matters (Use It or Lose It)

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

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Using placebo in the ED

Worked like a charm.

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Patient satisfaction and physician compensation

Panda Bear: "And as I am currently negotiating a contract where part of my bonus is going to depend on patient satisfaction scores, not only am I going to have pre-printed prescriptions for Percocet with my address and pager number in case the patient’s dog eats the pills, but I can see how happy patients are going to be good for my bottom line."

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The fatal flaw of universal coverage

Jay Reding: "You can't simultaneously reduce the cost of a service and increase access to it." (via Scalpel)

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Can a one-armed person be a surgeon?

Sid Schwab: "It'd be darn hard - probably impossible."

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Coding clinic

The Happy Hospitalist chronicles Medicare's ridiculous coding rules.

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Wikipedia doesn't link to health support groups

Should it?

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There is no business like medicine

Indeed:

Who else would spend countless hours working (oft in the middle of the night) with patients euphemistically referred as "self-pay" knowing full well that they will not get paid at all? Your lawyer? Your plumber? Your favorite movie actor? I dare say nay. I honestly cannot think of many examples, yet almost all of the physicians I know do pro bono work frequently; it's just another part of being a physician in the 21st century...

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The new Medicare "never" events

Bob Wachter: "They are nowhere near ready for prime time."

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Personal health records

Making health care less efficient?

Patients could show up and hand over their memory stick or a Internet address for the files, but doctors on the receiving end might be wary of believing what the records says. “It’s outside a protected chain,” Leiber says. “The second doctors are going to repeat those tests.”

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Insidermedicine: In the Clinic - Wolff-Parkinson-White Syndrome

In the Clinic - Dr. Chris Simpson, MD Discusses Cardiac Electrophysiology and Wolff-Parkinson-White Syndrome

Thanks to Insidermedicine for their continuing sponsorship at Kevin, M.D.

Insidermedicine (www.insidermedicine.com) is a physician-led news organization that brings daily evidence-based updates to patients, doctors and medical students. Also available in Chinese and Spanish.

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MedPage Today

I would like to thank MedPage Today for their continuing sponsorship at Kevin, M.D.

MedPage Today is the only medical news service for physicians that links consumer medical news and the professional medical analysis needed by clinicians.

Key to this site is their partnership with the University of Pennsylvania School of Medicine, where faculty review breaking news articles. With their Teaching Briefs, MedPage offers a reliable, physician-reviewed, source where both doctors and patients can digest breaking medical news. For those interested in the "bottom-line", Action Points introduce each article, emphasizing the take-home message.



Physicians and other healthcare professionals can accrue CME simply by reading the news. Articles are accompanied by a CME Post-Test, where AMA PRA Category 1 Credits can be obtained, without a fee.



Read more about MedPage Today.

Sponsorship opportunities continue to be available. This can be via a Standard Blogad or a customized package. Please visit the advertising information page for further details.

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Radiology and overtesting

Stark Raving Med: "Some radiologists really want to do the right thing. Some don't and just want to take your money. But the ones who do continue to produce thoroughly researched excuses for you NOT to order that imaging test. And when you get sued, at least you'll have the evidence on your side. Of course you'll still lose, but you can at least take a little solace in being right."

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Physicians should be in charge of implementing EMRs

Not enough are, which is why so many of them fail.

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How to make your hospitalist's life easier

Fat Doctor thanks you very much.

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"Clorox hunger"

The Washington Times: "A hunger so painful it feels like your stomach is being eaten by bleach or battery acid."

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