There is scope for harm when ordering tests

As the world speeds up we tend to assume that newer must be better. In some instances it is but when it comes to health, less so than one might expect. The other tendency is to overlook simple solutions and go to complicated, and often expensive ones.

In medical practice there is one step even before considering what to do with a given problem and that is whether there is a need to “do” anything. The great-untold story of health and medicine is that much of what ails us will actually resolve by itself and much will resolve by actions of the individual rather than what the doctor does.

I know this seems strange in an era where the solution to everything is go and see your doctor. It is a miracle that the human race made it to the 21st century without every symptom being checked by a doctor and treated accordingly.

An interesting piece in the New York Times, which drew on a commentary in the Journal of the American Medical Association, described “clinical inertia.” This is where doctors are “slow” to act. This term has slightly negative connotations but was described as being a safety valve. When I was in medical school the old school professors used to talk of “masterly inactivity” whereby the doctor would allow the body to heal itself rather than prescribe something or order tests.

All forms of medical interventions have potential side effects. When we are dealing with acute appendicitis the potential complications of surgery can be accepted, as it is a life and death situation. The same complications would not be acceptable in seeking to remove the appendix from someone who did not have appendicitis.

Someone who has pneumonia caused by a bacteria will need an antibiotic and notwithstanding that they may experience side effects, the benefits outweigh the harm. The same side effects are not as acceptable if an antibiotic is taken to treat a viral sore throat where there will be no benefit at all.

When it comes to ordering tests there is scope for harm. The notion of a simple blood test has appeal but no blood test is simple. A false result can lead to more tests and unnecessary treatments as well as needless anxiety. An unnecessary scan adds to cumulative radiation exposure

Screening tests like the PSA have now been shown to do more harm than good. For each man who benefits from having surgery for an otherwise undetected cancer, some 49 have needless surgery and more have needless biopsies and may suffer bleeding or infection as a consequence.

In conditions like high blood pressure and diabetes, adding more tablets when readings are close to the borderline can be seen as “good control” but can expose people to risks on the downside such as falling due to fainting or low blood sugar.

The relentless push of government and academic driven guidelines has created a mentality, which regards treating numbers as more important than treating people. Financial incentives in some health systems reward doctors who achieve certain “targets.” Doctors who have conflicts of interest are increasingly writing the guidelines. In particular they may be consultants to companies making medications to treat the condition, which is the subject of the guidelines.

A BMJ study showed that 48% of doctors involved in setting clinical practice guidelines for diabetes and cholesterol between 2000 and 2010 had conflicts of interest. A further 11% who said they had none actually had at least one.

The notion of doing tests “just in case” assumes that tests are infallible and that only good can come from them. The reality is that harm can come from any medical intervention. This does not mean they should not be done but in every case there is a trade off of risk versus benefit. Protocols can never allow for this individual variability.

Are there solutions?

  1. Most symptoms that we experience are not due to disease. A cough may be a symptom of lung cancer but hardly anyone who coughs has lung cancer. Likewise with a headache and brain tumors.
  2. Most conditions we see today are not acute emergencies and hence can be given time to resolve themselves. You do not always have to run to the doctor at the first sign of any symptom. Listen to your body.
  3. Tests and treatments have an important role but are never free from potential harm. We must always balance the benefits against the risks.
  4. We need to get back to treating people and not numbers so as to please governments and academics.
  5. The process of setting guidelines needs to be cleaned up.

Fire can cook your food but unchecked can burn down the house. Medical technology can save, enhance and extend life, but unchecked, can be harmful too.

Joe Kosterich is a physician in Australia who blogs at Dr. Joe Today.

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  • Paul Levy

    Very well stated!  Thank you!

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Great article. It still should be about talking to the patient with a thorough and complete history , followed by a detailed examination for the purposes of forming a hypothesis or differential diagnosis of what is wrong. You then choose your tests to support or refute your hypothesis. The art is being able to know when you can sit back and let the body heal itself, while developing and having the patients trust to accept that recommndation

    • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

      The art of medicine is what we need to recapture

  • Anonymous

     >>>”For each man who benefits from having surgery for an otherwise undetected cancer, some 49 have needless surgery and more have needless biopsies and may suffer bleeding or infection as a consequence.”

    Do you express the same caution for healthy women who carry the brca gene, but opt for prophylactic mastectomies because breast cancer runs in their family?

    • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

      A gene does not equal cancer. Caution is always warranted when we are playing a guessing game about who may benefit from surgery

  • susan256

    Excellent points and should give us all pause before demanding MRIs and CT scans. It’s easy to get caught up in the hype of new technologies and demand an immediate medical fix, but as you say, it can lead to more harm than good. Reminds me to take the time to ask questions, explore options and weight the pros and cons of cost, effectiveness and harm.

    http://whatstherealcost.org/video.php?post=five-questions

  • Anonymous

    Hi Dr. Joe – excellent and eminently sensible overview here. I like your old med school prof’s term “masterly inactivity” over “clinical inertia”. Some docs call this “watchful waiting” which also implies a more positive pro-active stance.  Trouble is: many patients don’t care what you call it, they expect ACTION, not INaction. My friends who are physicians sometimes grumble that they can spend 10 minutes with a patient carefully explaining why the test/drug/procedure is not appropriate, but at the end of the 10 minutes, the patients may still say: “Where’s my prescription?”

    On the other hand, I feel a wee bit nervous when doctors start grumbling about too many tests – because at the far end of this spectrum are those female patients (I was one of them) who are patted on the head and sent home from the Emergency Department in mid-heart attack – with misdiagnoses ranging from anxiety to acid reflux  or menopause.  In fact, the Emergency doctor took one look at me (despite my presentation with textbook heart attack symptoms like chest pain, nausea, sweating and pain radiating down my left arm) and he pronounced confidently: “You’re in the right demographic for GERD!”  Another survivor I know had to go back to Emergency three times with increasingly debilitating cardiac symptoms, yet was sent home each time; on the third visit, the Emerg doc suggested she might want to consider taking antidepressants.  On her fourth visit, she underwent double bypass surgery. 

    It’s hard enough for women to be taken seriously during a cardiac event (the New England Journal of Medicine reported that women heart attack patients under age 55 are SEVEN TIMES more likely than men to be misdiagnosed and sent home compared to their male counterparts presenting with the same symptoms). A wholesale reluctance to withhold appropriate cardiac tests for women is actually what many of us are fighting against.
    cheers,
    C.

    • Michal Haran

      As opposed to what it may seem, what you are describing is not “the other side” of the coin, but another aspect of the same coin-which is over-reliance on tests and not true and individualized clinical assessment. The main reason for misdiagnosis of coronary disease in women is that their presentation tends to be atypical (as compared to men) and their tests tend to be (confusingly) normal. Hence the (wrong) notion that women are unlikely to suffer from CAD.  Albert Einstein said-
      “Everything should be made as simple as possible, but not simpler. …. ”Not everything that countscan be counted, and not everything that can be counted counts.

      A few years ago, a patient was referred to my clinic because of symptomatic anemia. She indeed had (very mild anemia, which was easy to see by the numbers) but her symptoms to me were CAD. I called the referring physician and he reassured me that they have considered that possibility, but all her tests (stress test etc) were completely normal. I then called the cardiologist, who said the same. He was aware, like me,  that those tests are less diagnostic in women, but he then said that although it is true that her symptoms are worse on exertion,  they are not typical of CAD because she also complains of generalized pain. I insisted that he take her to the cath. lab. and he reluctantly agreed. She went straight from there to CABG for severe triple vessel disease. 

      Putting so much emphasis on treating numbers, takes a physician away from what is really important-the patient. Diagnostic tests, when used wisely,  are an excellent tool to support a clinical diagnosis or help stratify a disease according to treatment and prognosis. They can become a health hazard when used inappropriately, either leading to needless anxiety, further tests and dangerous interventions (when they are false positive) or giving false reassurance to physician and patient (when they are false negative).

    • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

      Thanks Carolyn. What we need is to return to the art of medicine and not do “cookie cutter” medicine. Tests are useful if used correctly but harmful if not- a bit like fire really.

  • http://www.facebook.com/people/Arnold-Wax/100000381145770 Arnold Wax

    Exceptional statement. As Einstein stated “technology will replace humanity.” It is certainly easier and far less time consuming to order “tests” than to actually examine a patient and cognitively evaluate them. It is more lucrative as well, especially if the equipment is self owned.
    Doctors have become slaves to the dogma of the PET scan, the MRI scan, the CT scan, and have drifted away from the trinity of the examination, the evaluation, and the pleasure of making a diabnosis by cognition.
    When, and only when, the current payment system changes, will doctors realize the benefit of intelligence over technology, and will again begin to think before acting, and become physicians again.

    Arnold Wax MD FACP CHCQM

  • http://www.facebook.com/people/Arnold-Wax/100000381145770 Arnold Wax

    Exceptional statement. As Einstein stated “technology will ruin humanity.” It is certainly easier, and far less time consuming to order “tests” than to actually examine a patient, and cognitively evaluate them. It is more lucrative, and mopore fallible, if the testing equipment is self owned.
    Doctors have become slaves to the dogma of the PET, the MRI and the CT scan gurus, and have ran away form the trinity of the physical examination, the solving of a diagnostic dilemma and the pleasure of making the correct diagnosis, through empiricism.
    Only when the current payment system changes, will doctors realize the benefit of intelligence over technology, and will again “think before acting” and once again become physicians.

    Arnold Wax, MD FACP CHCQM