An excerpt from At Peace: Choosing a Good Death After a Long Life. Copyright © 2018 by Samuel Harrington, MD. Reprinted with permission of Grand Central Publishing. All rights reserved.
Some would argue that more care for the elderly is better. They are sicker. They are weaker. We must fine-tune their care. We must examine them more closely.
A group of my colleagues made the bulk of their income by doing comprehensive annual physical exams. The yearly physical exam was part of the foundation of medical care when I began my practice. Since the 1990s it has been discredited as beneficial, but has lost little traction in practice. Studies show that the annual physical and its associated tests inflate cost and do not reduce morbidity and mortality. This fact is lost on the general public and ignored by those physicians performing “executive physicals.”
Here is an example of how an annual physical combined with unnecessary testing does harm, or at best, no good. Several years before leaving practice, I met a charming eighty-year-old woman, who lived with her equally charming, but more debilitated, sister. At the time of her annual physical exam, her diligent internist found her to have a slightly low blood count and a trace of blood in her stool. The low level of her blood count is a common, usually harmless, finding in the elderly. However, her internist referred her with the expectation that I would proceed with scope tests of her colon and stomach to exclude a potentially serious disease.
I talked the patient out of a colonoscopy. She had undergone such an exam by another practitioner within the last ten years and had probably maximized her (statistical) benefit at that point. I feared that the preparation would be very stressful and probably suboptimal.
We settled on an upper endoscopy to rule out benign blood-losing lesions and hoped that we did not find an unsuspected gastric malignancy. Unfortunately for her, I found a medium-size, flat, and benign growth on the inner curve of her duodenum (small intestine). Biopsies proved it to have pre-cancer potential. My bias, which I explained to her as both my professional opinion and a biased opinion, was to leave well enough alone. The lesion was at risk to grow and bleed, but it was a small risk. To manage it aggressively (that means to cut it out) would have required surgery (too aggressive at her age) or serial endoscopies to remove it piecemeal (the current standard of care). Each endoscopy would carry the small but cumulative risk of bleeding, perforation, anesthesia, and other complications. Given her age, it probably would best be managed through benign neglect.
A triangulated conversation with the referring physician resulted in a second opinion with an aggressive academic endoscopist. The patient underwent serial endoscopies, and ultimately the lesion was removed without serious complication, although the frequent outpatient trips put stress on her sister and ended when the sister fell in the hospital and fractured her pelvis. They had learned a lesson and wisely refused the recommendations of the academic endoscopist for regular follow-up examinations to monitor for a possible recurrence.
It is clear that the only one who definitely benefitted from this treatment plan was the other endoscopist.
As I matured as a gastroenterologist, I began to see that most doctors and patients envisioned no end to the usefulness of screening exams and associated testing. When to start screening and when to end screening are fundamental questions that medical science should be refining and redefining on a regular basis, but practitioners and patients resist any limitations. It was instinctively clear to me that some age existed after which screening did more harm than good.
During the last five years of my practice, I was regularly turning people away who were referred for a screening colonoscopy. I advised them that a preemptive exam was unlikely to help them and might harm them. The vast majority of patients left the office saying, “Thanks, Doc, I like that advice. I will call you if I have a symptom.”
Samuel Harrington is a gastroenterologist and author of At Peace: Choosing a Good Death After a Long Life.
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