A patient is shown inside a scan at Cedars Sinai Medical Center. A recommendation… (Los Angeles Times )
In case you missed it, a recommendation came out last month that physicians cut back on using 45 common tests and treatments. In addition, patients were advised to question doctors who recommend such things as antibiotics for mild sinusitis, CT scans for an uncomplicated headache or a repeat colonoscopy within 10 years of a normal exam.
The general idea wasn't all that new — my colleagues and I have been questioning many of the same tests and treatments for years. What was different this time was the source of the recommendations. They came from the heart of the medical profession: the medical specialty boards and societies representing cardiologists, radiologists, gastroenterologists and other doctors. In other words, they came from the very groups that stand to benefit from doing more, not less.
Nine specialty societies contributed five recommendations each to the list (others are expected to contribute in the future). The recommendations each started with the word "don't" — as in "don't perform," "don't order," "don't recommend."
Could American medicine be changing?
For years, medical organizations have been developing recommendations and guidelines focused on things doctors should do. The specialty societies have been focused on protecting the financial interests of their most profligate members and have been reluctant to acknowledge the problem of overuse. Maybe they are now owning up to the problem.
And judging from the content of the list, testing is a big part of that problem. Only a quarter of the recommendations fell in the category of "don't treat" — as in, don't prescribe more chemotherapy for end-stage cancer that is beyond hope. The remainder fell in the category of "don't test."
Because it can be the first step in a cascade of medical interventions, the focus on testing makes good sense. The specialty boards seem to now recognize that the results of testing include both signals (useful information) and noise (false and distracting information). For patients with symptoms the signal predominates. But for those without symptoms the noise predominates. And the noise is not harmless, it can trigger overdiagnosis and overtreatment. "Routine" chestX-rays, for example, have a way of unearthing multiple abnormalities. This raises questions in physicians' minds — triggering CT scans, needle biopsies, bronchoscopies and even surgery in an effort to answer them.
That's why multiple recommendations have argued against routine use of tests such as cardiograms (EKGs), ECHO and CT scans in asymptomatic patients — and against repetitive testing in patients whose symptoms have not changed.
Admittedly, some of the recommendations seem brain-dead obvious.
Don't screen for cancer in dying patients. (How could they possibly benefit from the early detection of a cancer that will not have time to progress?)
Don't screen for cervical cancer in women who don't have a cervix. (How could they possibly be at risk for cancer in an organ they no longer have?)
You might think such guidance would be unneeded. Sadly, research using the Medicare data has demonstrated both those things regularly occur.
Other recommendations have been around for years. Don't order CT scans and MRIs on patients with nonspecific low back pain. Don't order routine preoperative chest X-rays. Yet those orders continue.
Most doctors will agree with the recommendations on the list. But the problem of overuse is less one of bad doctors (although there are a few); the problem is more one of good doctors working in a bad system.
The truth is there are many forces that push us to do more. There are the performance measures that typically give doctors good grades for ordering tests, rather than for not ordering them. There is the legal system that will punish us for underdiagnosis, but not for overdiagnosis. There are the demands from patients seeking to get their money's worth from insurance after years of being taught to believe the best medical care is the most medical care. And there are the financial rewards: Most doctors, and/or the clinics and hospitals they work for, are paid more if they do more.
But we have to start somewhere — and this list is a good start. Now it needs to be extended.
Personally, I would have liked to see the recommendation "Don't perform breast or prostate cancer screening unless the patient understands both the harms and benefits." Or perhaps we could think even more broadly: "Don't feel compelled to end every patient encounter with an order for a test, a recommendation for a procedure or a prescription for a medication."
H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, is an author of "Overdiagnosed: Making People Sick in the Pursuit of Health."