Doing more than necessary in medicine is the opposite of safe

In case you missed it, former President George W. Bush had a stent placed in one of the arteries that feeds his heart.

The 67-year-old came through the procedure with flying colors, we are told. Stents are tiny metal mesh tubes that get inserted into clogged arteries, essentially to prop them open.

Bush, heretofore thought to be in excellent shape, seems an unlikely candidate for the procedure. We hear tale of him riding his bike, running, controlling his weight, avoiding tobacco and alcohol, and having a low cholesterol. His stress level is remarkably lower than just a few years ago. In terms of heredity, his longevity seems assured: his parents are both alive and near 90.

If he were my patient, I would not have ordered a stress test; the pre-test probability of finding coronary disease was extremely low. It’s not just because I’m a minimalist. I would be following the best available scientific evidence on the issue.

Of course, in the real world we don’t all follow the wisdom of the sages. He is a former president, after all. If I were his doctor, I’d work toward immortality for him, too.

Here’s the thing: stents don’t help us live longer. They are merely a form of symptom control for angina — that weird word that means chest pain caused by narrowing of the coronary arteries. And Mr. Bush had no symptoms. One non-indicated test (the stress test) begat another (a CT scan of his heart arteries) … and so on through to a risky and costly procedure of dubious value in his case.

Stents cost more than the alternative. They’re no better in terms of outcome than medical management, our term for using effective pills that provide the same amount of disease-specific longevity. Most importantly, having a stent placed involves real risk: bleeding, kidney failure, infection, abnormal heart rhythm, tearing the blood vessel.

Daily pills, you say? Yuck. But having a stent placed also requires at least one additional daily pill. So no real trade off there.

Luckily for Mr. Bush, we live in a place where free enterprise is a core value. Yes, even in health care. Especially in health care, where there’s inherent information asymmetry between buyers and sellers. We doctors are free to peddle our wares; is it surprising that paying customers sometimes get a touch more than they need?

“Just to be on the safe side,” we rationalize. Yet in medicine, doing more than necessary is the opposite of safe.

It’s human nature to want to do more. Fighting human nature is an uphill battle.

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • buzzkillerjsmith

    I’m not sure why he had the stent either, but the chatter assumes he had no symptoms but an abnormal TMT. If so, he should never have had the TMT.

    The same issue comes up, on a smaller scale, with routine blood testing with panels. How many times have we all chased mildly elevated LFTs, scaring the pt and creating more expense and more work.

    I remember driving down I 95 in the Philadelphia area five or six years ago and being stunned to see a huge billboard from some rads group pushing screening CT scans. This is in spite of explicit discouragement of this by the ACR.

    Patients don’t usually know. They have to rely on us and a lot of times we let them down. Just say no to over-testing.

    • Maura69

      I agree with you completely but the trouble is (w/ACA), I have a patient that I take care of with severe dizziness, light-headed, bottom out blood pressure on standing and a gait that is so terrible looks like he is drunk. He goes to a Pain Interventionist, Cardiac Physician, Orthopaedic, and PCP. The PI wants to inject more steroids in the spine and cervical, the Neurosurgeon (I forgot to mention) says Carotids are 53% and 62% occluded – NO surgery, the Cardiac says, (after repeated carotid exams etc) go to PCP, PCP say cut BP medicine in half. It is now September and this has been going on since January. I forgot the Ortho wants to do another procedure on his knee implant and gives another script for a narcotic…I have finally demanded the PI send him to a specialist so that he can have a Tilt Table. Everyone is handing the ball to someone else or to me…I am not an MD but all of the physicians say to me you know how to take care of him and tells this gentleman to listen to me. I am a retired RN and have taken care of this person for a long time but since this ACA has come into effect, especially for Medicare/MediCal the response has been awful. Just trying to see the physician…this individual needs to have the Tilt Table exam and then we go from there but meanwhile he is miserable, unable to drive and his health is declining…Too much or too little………….

  • Tran

    When you are not a doctor, it is easy to get “talked into” various medical interventions. I can imagine crystal clear, how someone like Mister Bush could be told, “These are the tests you need”, and then once we have those test results, “based on these test results, this is what we must do next”, and onwards.

    Things cascade like that, and before you know it you are fixing problem “a”, which showed up on test “x”, not because problem “a” ever bothered you, but because when test “x” comes up with result “y”, then procedure “aa” to fix “a” is simply the accepted next step.

    My own mother gets intimidated into taking tests I don’t think she needs, but she’s afraid to turn them down, “just in case”.

  • Tiredoc

    The stress test was indicated. Based on the results, the CT was indicated. The stent was not. There was no compulsion to put in the stent. Doctors are not automatons, with obligations to perform procedures because of test results. I would have used the results to better motivate Mr. Bush to take the medicine.

  • katerinahurd

    Under what conditions would providing more health care result in safer care? What are the provisions under which it is safe to provide preventative health care? Is the question to a physician a question of when, but not if, a medical intervention should be performed?

  • medicontheedge

    The better your insurance and ability to pay, the more you are sold. Simple, really.
    “evidence based” is NOT a word insurers and payors use often, except to deny coverage for certain populations.

  • elizabeth52

    I couldn’t agree more.
    Most women are having unnecessary pap tests, but the evidence has simply been ignored. I’ve always felt the millions made over-screening and over-treating huge numbers of women is behind the recommendations. It’s horrible to see the fall-out, so many women left worried and harmed. Most women are not giving informed consent, many provide no consent at all.

    It should be a scandal. So much damage to screen for a cancer that was always rare and in natural decline.

    When you compare America and Australia with countries like the Netherlands and Finland, the difference is stark, the former do not follow the evidence, practice and protect profitable and harmful excess, they maximize risk for no additional benefit to women. Vested and political interests should not be allowed to control and influence these programs.

    Finland and the Netherlands have made an effort to protect all women, the small number who might benefit from evidence based screening (not over-screening) and the vast majority who cannot benefit and are simply exposed to risk with testing.

    The new Dutch program will take most women out of pap testing and harms way and will save more lives by identifying the small number at risk. Women will be offered 5 HPV primary tests, or they can self-test for HPV with the Dutch-invented Delphi Screener, at ages 30,35,40,50 and 60 and ONLY the roughly 5% who are HPV+ and at risk will be offered a 5 yearly pap test. (until they clear the virus)

    Population pap testing drags in all women (or tries to) when most are not even at risk, and tragically, lots end up over-treated. (damage to the cervix can mean premature babies, c-sections, miscarriages etc.)
    Even before the significance of HPV was well-known there was no need to harm so many, since the 1960s the Finns have had a 7 pap test program, 5 yearly from 30 to 60, they have the lowest rates of this rare cancer in the world and refer far fewer women for “treatments” and excess biopsies.

    The American practice of ADDING the HPV test to pap testing is not in the interests of women, it simply generates the most over-investigation. Great for profits, a lousy deal for women.
    The HPV test should stand alone as the primary test.

    With most women in the dark, I fear excess will be the norm into the future for many women.

    Mammograms, same thing, no informed consent, no balanced information, risks suppressed, benefits exaggerated, a profitable numbers game. Thankfully, the Nordic Cochrane Institute were so concerned at the misinformation being given to women that they produced, “The Risks and Benefits of Mammograms”, it’s at their website. It should be given to every woman, but that won’t happen, too much money is made from breast screening. It’s not in “their” interests to provide real information that might put women off screening.

    As a low risk woman it was an easy decision to decline pap tests over 30 years ago now and more recently, I also, declined breast screening. My doctor has accepted my informed decisions, marked my file and that’s the end of it. There are lots of doctors out there who’ll put you first, it’s worth the hunt to find them. I don’t blame individual doctors, but medical leaders, medical associations and the government should have acted long ago to ensure these screening programs were evidence based, acting within proper ethical standards and respecting informed consent. (including our right to decline testing) That hasn’t happened, I’d say what we’ve seen is closer to medical abuse.

  • Stephen Rockower

    In our state, a doc had his license yanked for putting in stents where the indications were marginal at best. Sometimes, you should do only what’s necessary, not everything possible…