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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