With the guidance of an experienced and thoughtful physician I just made a decision to end a course of diagnostic testing after slowly getting to that decision point.
But I have family members and friends who have gone through a full “best practices” diagnostic regimen only to wind up in an ambiguous situation, then having treatment that may or may not have been necessary, too often without getting a second opinion.
So, as usual, I started Googling:
Dr. Atul Gawande a prominent Harvard Medical School Professor of Surgery and New Yorker writer reflected on eight patients he saw in his practice one day, after reviewing their medical histories.
“To my surprise, it appeared that seven of those eight had received unnecessary care. Two of the patients had been given high-cost diagnostic tests of no value. One was sent for an MRI after an ultrasound and a biopsy of a neck lump proved suspicious for thyroid cancer. (An MRI does not image thyroid cancer nearly as well as the ultrasound the patient had already had.) The other received a new, expensive, and, in her circumstances, irrelevant type of genetic testing. A third patient had undergone surgery for a lump that was bothering him, but whatever the surgeon removed it wasn’t the lump—the patient still had it after the operation. Four patients had undergone inappropriate arthroscopic knee surgery for chronic joint damage. (B)
Dr. H. Gilbert Welch, a professor at Dartmouth Medical School, and a nationally recognized expert on the effects of medical testing, wrote “….. the conventional wisdom is that more diagnosis—particularly, more early diagnosis—means better medical care. The logic goes something like this: more diagnosis means more treatment, and more treatment means better health. This may be true for some. But there is another side to the story. More diagnosis may make healthy people feel more vulnerable—and, ironically, less healthy. In other words, excessive diagnosis can literally make you feel sick. And more diagnosis leads to excessive treatment—treatment for problems that either aren’t that bothersome or aren’t bothersome at all. Excessive treatment, of course, can really hurt you. Excessive diagnosis may lead to treatment that is worse than the disease.” (C)
In another article Dr. Welch wrote this case study (very abbreviated here, link to full text is in the footnotes)
“Mr. Nadeau was eighty-five and in excellent health. He went to see his doctor simply for a routine checkup. The doctor performed a careful physical exam. Everything looked good, except for a bulge he thought he felt in Mr. Nadeau’s belly—a bulge that might be an abdominal aortic aneurysm. ….
The ultrasound showed that Mr. Nadeau’s aorta was normal…But the ultrasound found something else to worry about. It found something abnormal on Mr. Nadeau’s pancreas….A CT scan showed the pancreas was normal.
But the CT scan found something else to worry about. It found a nodule on Mr. Nadeau’s liver. The radiologist recommended a liver biopsy to see what the nodule was (it could be cancer too). ….The pathologic diagnosis was hemangioma, a benign growth made up of lots of blood vessels.
Given that a small knitting needle was cutting through a growth full of blood vessels, you won’t be surprised by what happened next. Bleeding. Mr. Nadeau was in the hospital for a week……
That’s too much medicine. (D)
Here are some ways you can play a role in assuring appropriate levels of diagnostic testing:
1. Do some homework using CHOOSING WISELY. Choosing Wisely is an initiative of the ABIM Foundation in partnership with Consumer Reports that seeks to advance a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. http://www.choosingwisely.org/
2. Five Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure. Do I really need this test or procedure? What are the risks and side effects? Are there simpler, safer options? What happens if I don’t do anything? How much does it cost, and will my insurance pay for it? (E)
3. Second opinions are fairly routine. They bring peace of mind and encourage patient engagement… “If your physician doesn’t support you getting a second opinion, see how fast you can run.”… “Any doctor who is any good at what they do will welcome a second opinion, because it will usually be a confirming opinion.” (F)
4. As you get referred to specialists make sure your PRIMARY CARE PHYSICIAN keeps fully informed, coordinates your care and helps you fully understand your options.
(A) Over-Testing, Over-Diagnosis & Emergency Medicine: Does it Exist and Does it Matter?, by Rick Bukata, https://medium.com/@emabstracts/over-testing-over-diagnosis-emergency-medicine-does-it-exist-and-does-it-matter-fabc10d9e252
(B) Overkill, An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? by Atul Gawande, The New Yorker, http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande
(C) ‘Overdiagnosed’ by Gilbert Welch et al, NYT, http://www.nytimes.com/2011/01/25/health/25zuger_excerpt.html
(D) There Is Such a Thing As Too Much Medical Care, by H. Gilbert E. Welch, http://www.sciencefriday.com/person/h-gilbert-welch/
(F) A Patient’s Guide to Second Opinions, by Kristine Crane, http://health.usnews.com/health-news/patient-advice/articles/2014/07/23/a-patients-guide-to-second-opinions
Note: This blog shares general information about understanding and navigating the health care system. For specific medical advice about your own problems, issues and options talk to your personal physician.